An exploration of the support needs of Ambulance Paramedics This is a thesis submitted in fulfilment of the requirements of the degree of Doctor of Philosophy. Sandra Porter Bachelor of Psychology (Honours) Master of Applied Psychology (Community) Doctor of Philosophy 2013 College of Health and Biomedicine Victoria University Abstract The work of ambulance paramedics is usually physically and emotionally draining and can place significant amounts of pressure on the emergency service worker. The work they do can impact their social life, their family and ultimately, their health. The primary aim of this research was to explore the psychological and social coping strategies of ambulance paramedics, in dealing with the day to day aspects of their work in the context of their long term health and well-being. A secondary aim was to examine the use of current peer support programs and other referral services used by paramedics. This study was a qualitative exploration of the experiences of ambulance paramedics through interviewing. Qualitative research has allowed the researcher to capture the stories of individuals, in their own words. This study included nine novice paramedics (first year) and 12 longer term employed (five plus years) paramedics within Rural Ambulance Victoria. Participants were also recruited to reflect the gender ratio in the paramedic workforce. Findings indicate that: (1) despite length of service each paramedic has a story to tell which indicates they have been impacted by what they see, (2) their family and social lives are negatively impacted, (3) paramedics use many coping strategies -- both functional and dysfunctional, (4) paramedics have reservations about the type of support they request, and (5) there was evidence to suggest numerous participants have, or are, suffering from acute and/or chronic PTSD. These findings will contribute to our understanding of the work life of paramedics. Outcomes will further inform the development of “best practices” in improving the health of paramedics by providing an informed consideration of what the paramedic themselves consider to be valuable and accessible within the context of organizational support. ii Declaration I, Sandra Porter, declare that the PhD entitled “An Exploration of the Support Needs of Ambulance Paramedics” is no more than 100,000 words in length including quotes and exclusive of tables, figures, appendices, bibliography, references and footnotes. This thesis contains no material that has been submitted previously, in whole or in part, for the award of any other academic degree or diploma. Except where otherwise indicated, this thesis is my own work. Signature: Date: iii Dedication To the countless men and women in all emergency services around the world who put their lives at risk to serve, protect and save their communities. iv Acknowledgements I would like to thank Victoria University for giving me the opportunity to complete this PhD, and for the past 14 years when I first embarked on my academic journey as a 17 year old. I am resentful for still being here as a 31 year old-but at the same time feel very fortunate to be able to study at an institution where in my experience, students come first. I owe a great deal of thanks to many people without whose support this project would not have been possible. I would like to take this opportunity to express my appreciation. First and foremost the participants of this study who welcomed me sometimes into their homes, and engaged in the spirit of the research. I feel privileged to have been given the opportunity to listen to your story. I can only hope that this research benefits you, your colleagues and your families in some way. My supervisor, Professor Adrian Fisher, whose support, encouragement and wisdom, brought this thesis to its completion. Adrian took this thesis on, a few years through and it’s been amazing having his guidance, advice and support along the way. The last lap of the athletics track is finally complete! Dr Marion Kostanski and Dr Michelle Towstoless whose enthusiasm and expertise helped to develop my research skills and started the ball rolling on what has been a cloud hanging over my head for 5 years. The staff at Ambulance Victoria’s Department of Research and Evaluation who have assisted over the years, Paul Jennings, Linton Harriss and more recently Dr Amee Morgans. To the administration staff at Victoria University. Specifically Elizabeth Smith and Chris Raptopoulos who assisted at numerous times throughout the years with forms, paperwork, directing me to the appropriate staff, and procedures. Finally personal thanks to my family and friends who kept me sane throughout this long process. Many of you were probably sick and tired of hearing about this research and towards the end I got sick of hearing “Are you still doing that?” or “I thought you already finished that.” To my many amazing family members who helped with caring for our daughter, Arianna whilst I attempted to get this complete for examination before Baby Tsiotinas number 2 came along. For then stepping in again to help me with both Arianna and Jonathan during submission for classification. My mother in law and father in law, Despina and John Tsiotinas. You are truly amazing individuals and if I am half the parent you both are, I will be a happy person. You are two of the most selfless people I have ever met and am eternally grateful for your support, encouragement and love. To my sisters, Geri, Deirdre, Sinead and brother Sean. Thank-you for your encouragement and help throughout this long journey. I’m sure you’re all sick and tired of hearing about me going to Uni, meeting with supervisions, working on my thesis. I don’t know what I would do without all of you on a daily basis. To my own amazing parents, Jim and Susan Porter. Without both of you and your selfless decision to move to Australia with such a young family in 1988, I would not have had the opportunities which I have been blessed with here in Australia. You both moved away from your own families, impacting your own lives, in order to enhance ours. I will forever be thankful. I’ll be graduating 25 years, almost to the day of us arriving in Australia. I will always be grateful for the amazing support I have from family and friends. To my sweetheart Jim. Finally you will have me all to yourself, without any distractions. We made it! Thank-you. I love you MTA. v Table of Contents CHAPTER 1 .................................................................................................................... 1 SETTING THE SCENE ................................................................................................. 1 1.1 Impacts of the job ........................................................................................... 2 1.2 The Agency ...................................................................................................... 3 1.2.1 Ambulance Paramedics - Who are they? .................................................. 4 1.2.2 Paramedic training .................................................................................... 4 1.2.3 Work of Paramedics ................................................................................. 6 1.2.3.1 Ambulance Paramedics.................................................................................................... 6 1.2.3.2 Mobile Intensive Care Ambulance (MICA) Paramedic ..................................................... 6 1.2.3.3 General Transport Teams (GTT) or Non Emergency Patient Transport (NEPT) ............... 7 1.2.3.4 First Aiders and Ambulance Community Officers ............................................................ 7 1.2.3.5 Continuing Education ....................................................................................................... 8 1.2.4 What work do they do? ............................................................................. 8 1.2.5 Impacts of the job on the Paramedic ...................................................... 10 1.2.6 A Snapshot of the current state of Ambulance Paramedic Health ......... 12 1.2.7 Aims of the project ................................................................................. 12 1.2.8 Research Questions ................................................................................ 13 1.2.9 Statement of Significance ....................................................................... 13 CHAPTER 2 .................................................................................................................. 15 STRESS AND COPING ............................................................................................... 15 2.1 Stress Defined ................................................................................................ 15 2.2 Coping Defined ............................................................................................. 17 2.3 Selye’s General Adaptation Syndrome (GAS) ........................................... 18 2.4 Transactional Model of Coping and Social Support .................................. 20 2.4.1 Primary Appraisal ............................................................................................................... 22 2.4.2 Secondary Appraisal ........................................................................................................... 26 2.5 Stress and coping in Emergency Services................................................... 28 2.5.1 Application of Primary Appraisal in relation to Paramedics .................. 42 2.5.2 Application of Secondary Appraisal in relation to Paramedics .............. 44 2.5.2.1 To stay with the risk of failing ........................................................................................ 45 2.5.2.2 To be caught in turmoil .................................................................................................. 46 2.5.2.3 Guilt and shame ............................................................................................................. 47 2.6 Functional and dysfunctional coping .......................................................... 50 2.6.1 Burnout and PTSD ................................................................................. 59 2.7 Non coping profile of Paramedics ............................................................... 64 CHAPTER 3 .................................................................................................................. 68 ORGANISATIONAL RESPONSES – WHAT HAS BEEN DONE? ...................... 68 3.1 Ownership and Community Readiness ...................................................... 72 CHAPTER 4 .................................................................................................................. 78 METHOD ...................................................................................................................... 78 4.1 Participants ................................................................................................... 79 4.1.1 Novice Paramedics ................................................................................. 80 4.1.2 Experienced Paramedics ......................................................................... 80 vi 4.2 Procedure ...................................................................................................... 80 4.3 Interviews ...................................................................................................... 82 4.4 Data analysis ................................................................................................. 82 4.5 Ethical considerations .................................................................................. 84 4.6 Presentation of Results ................................................................................. 84 4.7 The Researcher ............................................................................................. 85 CHAPTER 5 .................................................................................................................. 87 RESULTS – DEMOGRAPHICS AND TRAINING ................................................. 87 5.1 Appeal of the job ........................................................................................... 87 5.2 Traditional on the job training methods versus University training in Australian context .................................................................................................... 88 5.3 University Course Issues .............................................................................. 91 5.4 Experienced paramedics versus Novice Paramedics ................................. 93 CHAPTER 6 .................................................................................................................. 98 RESULTS – CASE STUDIES ..................................................................................... 98 6.1 Harry ............................................................................................................. 99 6.2 Leah ............................................................................................................. 102 6.3 George and Maria ....................................................................................... 105 CHAPTER 7 ................................................................................................................ 111 RESULTS – THEMES ............................................................................................... 111 7.1 Reality of the work ..................................................................................... 111 7.1.1 Procedural Difficulties .......................................................................... 115 7.2 Sensitivity/Impacts of their work .............................................................. 116 7.2.1 Personality issues .................................................................................. 117 7.2.2 Major Holidays ..................................................................................... 120 7.2.3 Impact on family ................................................................................... 122 7.2.4 Jobs that affect or remain with participants .......................................... 127 7.2.5 Bad things happen ................................................................................ 131 7.3 Coping strategies used to manage their work .......................................... 131 7.3.1 Social support ...................................................................................... 133 7.3.2 Informal support .................................................................................. 136 7.3.3 Use of Humour ..................................................................................... 140 7.3.4 Other coping strategies ......................................................................... 142 7.4 Organisational support .............................................................................. 145 7.4.1 Peer support and confidentiality ........................................................... 147 7.4.2 Support from Management ................................................................... 149 7.4.3 Rural versus Metropolitan working environments ............................... 159 7.4.4 Shiftwork .............................................................................................. 161 7.4.5 Support needed ..................................................................................... 163 CHAPTER 8 ................................................................................................................ 166 vii CONCLUSION AND SUMMARY ........................................................................... 166 8.1 Training and Expectations ......................................................................... 167 8.2 Well-being ................................................................................................... 169 8.3 Coping strategies ........................................................................................ 171 8.4 Organisational Issues ................................................................................. 173 8.5 Impact on the Researcher .......................................................................... 177 8.5.1 Journal Entry 1 – After interview with paramedic – 16years in job..... 178 8.5.2 Journal Entry 2 ..................................................................................... 179 8.6 Future research directions ......................................................................... 179 8.7 Limitations .................................................................................................. 181 8.8 Final Conclusion ......................................................................................... 182 REFERENCES ........................................................................................................... 183 APPENDIX 1: EMAIL TO PARTICIPANTS ......................................................... 188 APPENDIX 2: PLAIN LANGUAGE STATEMENT PARAMEDICS ................. 189 APPENDIX 3: CONSENT FORM ............................................................................ 191 APPENDIX 4: INTERVIEW QUESTIONS ............................................................ 192 APPENDIX 5: VICTORIA UNIVERSITY ETHICAL APPROVAL ................... 194 APPENDIX 6: ETHICAL APPROVAL AV ............................................................ 195 APPENDIX 7: RELATED NEWS ARTICLES ....................................................... 196 viii List of Tables Table 1 Paramedics courses available in Victoria, Australia 5 Table 2 Factors which influence stress 23 Table 3 MAS and RAV contacts by Peers by presenting problem 71 Table 4 Themes for both experienced paramedics and Novice paramedics 112 List of Figures Figure 1 Transactional model of coping and social support 21 ix Chapter 1 Setting the scene Three people in the branch sit in silence. One reads the daily newspaper, another sits exhausted in a recliner, and the third busies himself by making a cup of tea. This is how shifts usually begin, especially if it is a few days into their roster rotation. As the morning goes by, conversation turns to recent jobs. Then, the pager goes off, seconds later the static begins followed by the voice of the radio dispatcher. Conversation ceases. One worker grabs the radio and some fruit from the bench, another is already out of the branch and in the van, the third remains at the branch, reviewing medications and medical procedures. This is the life of an ambulance paramedic. It is easy to see how this change in pace is not suitable to all individuals. Such a dramatic shift from doing something low key and mundane to having your heart rate increased within seconds can have many long term negative physical and emotional effects if not handled appropriately. For these reasons, and many others, terms such as burnout, post-traumatic stress, and vicarious trauma are commonly used within helping professions. Ambulance paramedics are unique in many ways. They are unlike other medical staff, who usually see patients in sterile, stable circumstances. Paramedics are usually the first helpers called in the state of a physical emergency of individuals. They run to the aid of all individuals and see things in many different settings, such as individual homes, on the street and under cars. Despite the importance of their role, there has been a lack of research relating to the health and wellbeing of paramedics both in Australia and globally. For this reason research on stress and coping, trauma regarding other emergency service workers will be used in this study. 1