Job Stress and Stress Management Among Detroit EMS Workers

Preston West City of Detroit Fire Department Emergency Medical Services Division Detroit, Michigan An applied research project submitted to the Department of Interdisciplinary Technology as part of the School of Fire Staff and Command Program August 21, 2003

Abstract Every EMS person is affected by stress daily, whether on the job or in their family life. If stress is not dealt with effectively, it can have a detrimental impact on his/her job performance, physical, mental, and emotional health, as well their personal, and interpersonal life. The purpose of this empirical study was to evaluate the stress level of Detroit Emergency Medical Service personnel, identify the job-related causes, and to propose actions that management might take to mitigate some job-related causes of stress. Since research has shown such a high degree of stress across all E.M.S. personnel, it was hypothesized that there was also a high degree of stress among the Detroit Emergency Medical Service personnel. The survey method was used to help determine the level of workplace stress of the. Procedurally, the survey forms were distributed to 120 on-duty E.M.S. personnel for completion and return. The survey form used was replicated from Managing Stress in EMS Personnel (Seaward, 2000). Fifty (50) forms (40%) were returned. The average total score for all subjects was 51.4, which indicates a high level of stress. While 11% of respondents were in the low stress category, fully 79% were in the moderate and high stress categories. 9% were in the very high stress category. Detroit Emergency Medical Service should develop a proactive stress management program to assist the personnel with their stress management requirements. In addition to the employers input, the EMS field personnel need to have a thorough understanding of stress and how to manage it with or without a structured stress management program in place. Research has shown that EMS personnel are much more productive when they manage their stress constructively. .

Table of Contents

Abstract2 Table of Contents.3 Introduction..4 Background and Significance..4 Literature Review6 Procedures and Population....26 Results28 Discussion and Implications..31 Recommendations..33 Appendix34 Sample Survey Bibliography/Endnotes.36

Introduction

Much has been written about stress levels among emergency services workers, and the high stress level of persons in this type of work is well documented (8, 15,24). Because stress often has a considerable negative impact on job performance, reducing job stress should be a high priority for well as all emergency medical services (8, 15). The purpose of this paper is to not only to explore the causes, and effects of stress, but also discuss, and propose possible ways for Detroit E.M.S personnel to manage it. The survey method will be used to help determine the level of workplace stress of the Emergency Medical Service personnel. Procedurally, the survey forms will be distributed to the on duty E.M.S. personnel. They will be asked to complete the forms and return them upon completion. The hypothesis for this research paper, is, that since research has shown that there is such a high degree of stress across all E.M.S. personnel; that there will also be a high degree of stress among the Detroit Emergency Medical Service personnel as well. If this hypothesis is true the Detroit Emergency Medical Service needs to develop a proactive Stress Management Program to assist the personnel with their stress management requirements. In addition to the employers input, the EMS field personnel will also need to have a thorough understanding of stress and how to manage it with or without a structured Stress Management Program in place. Research has shown that EMS personnel are much more productive when they manage their stress constructively.

In this empirical study, EMS workers in the Detroit Fire Department were surveyed to identify their perceived job stressors and measure degree of job related stress. These results can be used to design effective strategies for reducing job stress that will in turn result in improved job performance among these workers. Background and Significance

Far too many Emergency Medical Services are either not aware of the causes, the effects and or how to manage the stress of their personnel. In a letter written by Joel Demers (jrdemers@aol.com) he states This is a sad reminder of how we forget to talk care of ourselves and our fellow EMTS. The following story is true, and it breaks my heart, but I feel it is important to share. A new EMT named Sam was hired about a year ago, a quiet 26 year - old man hailing from Tennessee. He was quite the gentleman, saying please and thank you, never cursing in front of a lady, and so on Sam was everyones favorite partner; he caught on quickly, and never made any trouble. He was married, with two young girls, (Hers, not His). They had their problems but Sam was man enough to handle them at home, and never brought it to work. No one especially noticed, but recently Sam wasnt has jovial self, not cracking jokes, not socializing as much, not joining us for drinks, as was the norm. Some of us heard that his wife left him, and soon the rumor was confirmed. Sam kept a stiff upper lip, and spoke only once or twice of his marital problems. Then two and an half weeks ago, He was involved in a Police chase, driving erratically, hitting vehicles, and was reported by the count paper as to have been trying to commit Suicide by Cop: acting so dangerously to cause a police officer to shoot him.

Well, this didnt happen, rather he got away, later turning himself in to the police for reckless driving charges, He was processed, and released, returning to work the next day. Sam was restricted from driving for a short time a work, but otherwise suffered no penalty for the actions, until last week. He was called upstairs and relieved of his duties, yes, fired. Sam turned in his gear and left with not more than a few grumbles about the managers being sent to Hell someday. We figured this was the extent of his hostilities. This morning, at 0230, I got a call from dispatch asking me to come in and cover for a crew that was sent home after a traumatic call. I asked what happened, and the answer horrified me more than any news before. It had been reported that Sam was caught by the police after shooting and killing a 20ish girl whom he did not even know. He then fled, running and firing a gun at neighborhood homes. He ran into the woods, and was then chased out by a police canine, at which point, (No I didnt believe it at first either), Sam pointed the gun at a police officer. The officer quickly fires two shots at. Moments later, EMS arrived (his former co-workers) to find Sam in Traumatic Cardiac Arrest. The usual ALS and ACLS was initiated, and he was transported to the local hospital where he was pronounced dead. As best as we can figure, Sam really wanted to escape his life, but did not have it in him to kill himself. He felt the need to have some else do it. He succeeded, this time, sadly at the cost of anothers life. Sam exhibited many of the signs of depression/suicidal ideation, withdrawal, selfdestructive behavior, and irrational thought, but he didnt get the help he needed. The first police officer (2 weeks ago) did not commit him for a psyche eval, rather he was set free. His employer simply fired him. Now Sam is dead. Some feel he died as a violent criminal. I feel that Sam was neglected, and could not control himself. This is not an excuse for murder, but it does show that sometimes we ignore our co-workers feelings as just daily stress, when it may be a real

problem. So look at yourself, and your partner, and make sure you are not holding in so much stress that you may end up like my good friend, Sam. My heart goes out to that girls family, to Sams wife and step children, his parents, and especially my co-workers ion EMS, as we have lost a brother and a friend. (26) Though this did not happen to a member of the Emergency Medical Service Division of the Detroit Fire Department, but it could have vary easily, because the Department does not have in place a proactive stress management program. The goal of this research paper is: 1) To give the heads of EMS organizations (especially Detroit E.M.S.) everywhere, the information necessary, so they will have a thorough understanding about how much stress their personnel are dealing with on a regular basis. 2) Present a clear picture of stress, and the effects it has on their personnel. 3) Point out the causes of their stress, both on and off the job 4) Suggest ways for the personnel to manage or cope with their own stress. 5) Convince the Departments to implement a proactive stress management program, which will save time, money, loss of personnels services due to injuries and illness, and it just might save a life. The hypothesis in this paper is that Detroit E.M.S. personnel experience the same types of stress, as do other E.M.S. personnel. To assist in this effort I will have the E.M.S. personnel complete a confidential stress survey form adapted form the American Institute of Stress. This form will help me to determine the level of workplace stress of the E.M.S. personnel. It will also help to answer the question about whether Detroit E.M.S. personnel have the same kinds of stress experienced by other E.M.S. personnel

Literature Review Stress

The word stress was brought into medical usage by Austrian born Hans Selye, a professor at the University of Montreal. Selye published a book entitled Stress in 1950. He noted that in addition to specific physical changes in the body, such as a bruise from an injury or rash from measles, there are also nonspecific reactions that increase the bodys ability to adapt and reestablish normalcy. Siren noise, inclement weather, confined workspaces; poor scene lighting and life and death decision are all examples of environmental stress. Psychology stress can come from family relationships, conflict with coworkers, and abusive patients. The way in which an individual thinks and feels is personality stress. Each person has their own way of dealing with stressful situations. Individual reactions to stress are based on previous exposure to a specific type of stress, perception of the stressful event, experience and personal coping skills.

These are the stages of Stress: ALARM REACTION, THE BODYS RESPONSE TO STRESS The fight or flight phenomenon occurs when an emergency situation threatens the individuals safety or comfort. This is considered to be a positive reaction as it prepares the body to be alert and to defend itself. At first the bodys response to stress is unaffected by the type of situation being faced, It responds the same to pleasant, unpleasant, dangerous, exciting, happy and sad, The response purpose is to achieve top physical condition to cope with and event. The alarm reaction is controlled by the autonomic nervous system. It is coordinated by the hypothalamus. The hypothalamus causes the pituitary gland to release adrenocorticotropic hormone into the blood stream. The adrenocorticotropic hormones are called the stress hormones and they stimulate glucose production and increase the bloods concentration of energy production nutrients

necessary for the response to stress. Adrenocorticotropic hormones also activate the adrenal glands for release of adrenaline and noradrenaline, which creates and increase in heart rate, blood pressure rise and the pupils to dilate. This improves vision. The combination of adrenaline and noradrenaline relaxes the bronchial tree, causes deep breathing, slows the digestive process, and causes the blood to become ready for clotting should an injury occur. After all these events, the body is ready for an emergency. The alarm reaction only takes seconds and occurs when the body is first exposed to stress. The response stops when the body realizes that is not in danger. Body functions then return to normal.

STAGES OF EXHAUSTION: At first, the resistance to stress is above normal, but with time, it becomes exhausting. Resistance to other types of stress also decline as the body becomes susceptible to physical and psychological stressors. When patients are no longer able to resist stress, they enter into the exhaustion phase. This phase decreases resistance and physical and psychological activity return to the non-emergency state that exhausted before the crisis. Rest and recovery follow the exhaustion stage. After this, the patient is ready for another emergency. (25)

EMS Personnel Under Stress Besides the normal stresses in providing emergency care, EMS personnel often deal with the following:

OCCUPATIONAL STRESSORS Long or extended shifts Too much overtime Insufficient budget for equipment upgrades Keeping emotionally neutral between victims and perpetrators Management conflicts Poor advancement opportunities Poor peer support Little recognition Expectations of public Life and death issues Value conflict (dealing with minorities, immigrants, people of different religions or sexual orientations, etc Poor system designs Problems with supervisors Problems with instructors or physicians Bureaucratic (agency) conflicts Job burnout Expectations of the public Poor pay or other compensation Hazardous work conditions Mass casualty incidents Threats of terrorism

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 Dealing with the media Overeager citizens with police scanners Fear of inadequate training or not enough training Poor professional communication skills Not enough action Obstructive people

PERSONAL STRESSORS Lack of high-quality family time Lack of personal time Marital problems Financial difficulties Car problems, traffic Personal health concerns Death of family member

Effects of Stress on the EMS personnel William Rusty Scala M.A stated in a report on Programs to protect emergency personnel Police, Fire & EMS the following: The levels of cortisol (a potent stress hormone) in emergency personnel surge to provide energy to get them through a stressful event. But the body is designed to handle stress for short intervals not the chronic day in and day out stress of emergency work. Is it any wonder, then that police officer, firefighters and paramedic personnel have a higher rate

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of heart disease than any other group? Physical, emotional and mental stress, all elevate cortisol levels. In small amounts the body can adapt to elevated cortisol, but when cortisol stays elevated for long it becomes deadly to every system in the body. How a person handles stress can be influenced by their job, heredity childhood experiences, diet, blood type, exercise, sleep patterns, personal relationships, income and social status. Researchers have now demonstrated that physical, emotional, and mental stress can cause illness and disease by suppressing the immune system. Stress causes deficiencies in the disease fighting white blood cell along with vitamins, minerals, amino acid and essential fats. Adrenaline and cortisol, both stress hormones secreted by the adrenal glands, flood the blood stream during as stressful event. Stress events, from those emergency workers face to being stuck in traffic, set off a biochemical domino effect inside the body. The heart rate increases, blood pressure rises, respiration quickens and oxygen flow to the muscles increases. If for example, you get in an argument with someone this process kicks into overdrive. But when the stressful event is over the body sets off another group of responses that calm things down, restoring the body to normal. This process of equilibrium is essential for survival. However, as we age it becomes harder and harder to calm down after such events. That is why we see many more 60-year-old golfers than 60year-old emergency workers. With this process in mind, think about the damaging effect a false alarm has on an emergency worker. The alarm sounds. The body is poised and ready. The brain call to the adrenal glands and orders the lover to bump glucose and fatty acids into the blood stream be burned for immediate fuel. But because it is a false alarm the body never gets put into motion. The glucose and fatty acids are not burned up. They become oxidized and find a resting-place in one of the worst placesthe coronary

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arteries that feed the heart. This was one of the main reasons educated fire administrators removed loud alarms from some firefighters bunkrooms in the late 1970s.

The process can happen to very fit people. For instance, a man in his 40s who ran a 3 hour 7 minute marathon died when he crossed the finish line. His autopsy reveled that three arteries were 75% blocked and one was totally blocked, it was the totally blocked artery that caused the deadly heart attack. He was a very fit person who ended up with cholesterol clogging his arteries because he was under constant stress that caused nutrient deficiencies and elevated free radicals damage. Free radicals are like the sparks from a fire that fall on a carper. For the emergency worker, this carpet is his arteries. Far too many physicians confuse thinness, normal cholesterol and fast race times with health. Police, firefighters and EMS personnel must raise their own standard of care by becoming educated and requesting the new tests and treatment protocols that are currently available.

When stress persists for too long or becomes too sever, the body breaks down. Emergency workers are at the extreme end of the stress continuum and should be taken care of with new and improved treatment protocols designed for their specific metabolism. New training on stress induced nutritional deficiencies and how cortisol and free radical damage can lead to undetected heart disease should be taught in fire and police academies to ready those who work on the front lines. In one particular study scientists placed rats in small compartments where they added loud noise and constantly changed the temperature. Cortisol levels in rats began to elevate as their stress increased.

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After 21 days the rats were so anxious and aggressive that their immune system could no longer fight off sickness and brain cells atrophied in the hippocampus, the area of the brain responsible for short-term memory. Emergency workers need to understand there are new risk factors that most physicians are not aware of. So when it comes time for a physical, they should ask to be tested for elevations in C-reactive protein, homocysteine, and cortisol. Far too many workers get a clean bill of health and told their blood tests are normal when in reality they can be dangerously close too having a heart attack. Cholesterol is not the bad guy; it does not cause heart disease. If we train emergency workers as to how stress affects brain chemistry, immunity, heart disease and obesity, they can plug in early interventions so that they dont have heart attack a year after retirement. The constant stress of emergency work is severely debilitating to the brain, heart and immune system. New studies are looking at increased time off for people who work in stressful occupations so they can reset their bodys immune fitting mechanism. Sr. Sheldon Choen, professor of psychology at Canegie Mellon University, has found that volunteers inoculate with a cold virus, who reported life stressors that continued for more than one month, such as unemployment and family problems were more likely to develop colds than those who were under less stress. The longer the stress persisted, the greater the risk of illness. That immunity of a person in their 20s is more responsive than some in their 40s. These critical biological differences need to be assessed so proper protocols can be established and placed in standard operating procedures in order to protect emergency personnel. These men and women daily come in contact with biohazards and their immune systems need to be functioning at peak levels.

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If a person continues to respond to calls in a nutrient deficient state they will not only damage their adrenal glands, setting them up or chronic fatigue, but they will also damage their neurological system and cause brain damage. Sr. Joseph LeDoux of New York University states that when stress is chronic the brain is the target of damage. A decade of research has demonstrated that sustained stress and overproduction of cortisol can damage the hippocampusthe horse shaped structure involved in memory formation. Scientists say that the hippocampus plays an active role in registering not only events, but also their context, an important task when faced with danger. When emergency worker is responding to a call the hippocampus helps turn off the stress response when the call is over. But high levels of cortisol can cause nerve cells in the hippocampus to shrink and stop the creation of new brain cells. The evidence also links a smaller hippocampus with post- traumatic stress disorder, depression and over Training in athletes. But when the last time a physician ordered a cortisol saliva test for an emergency worker when they were fatigued or sick? This simple and inexpensive test can be a lifesaver. The current blood work cone only uncovers pathology and disease in its ate stages. (1)

Effectively Managing or Coping with Stress Effective coping is best defined as the mental process of managing demands that are appraised as a challenge to your resources. Ineffective coping, such as avoidance, is reflected in current national health problems: alcohol and drug abuse, battered spouses and children, hostile aggression, social violence, and suicide.

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FOUR COMPONENTS OF EFFECTIVE COPING STRATEGIES

1. Increased awareness of the problem 2. Information processing 3. Changing behaviors 4. Peaceful resolution

REFRAMING STRESSFUL THOUGHTS Excessive overtime hours. A drunk belligerent perpetrator. Numerous reports to file. A call in the middle of your anniversary dinner. A long distant transport. Stressors come in all shapes and sizes. It is not the circumstance or environment that is stressful, but rather the perception or interpretation of the situation. If the perception is negative, it can become both a mental and physical liability. Whatever the event, perceptions can magnify and distort it entirely out of proportion and turn everyday problem into catastrophic monsters. By learning to reframe your perceptions, you can avoid the pitfalls of toxic thoughts. (9)

TOXIC THOUGHTS Self-talk is a never-ending conversation running though your head. Most self-talk consists of negative thoughts, criticisms, and put-downs, or what are often referred to as toxic thoughts. Toxic thoughts are directly related to low self-esteem. Toxic thought perpetuate the cycle of low self-esteem by ignoring or destroying feelings of self-worth and self-acceptance. Negative thoughts are actually a response

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learned in childhood that carries into adult life. Studies show that a pessimistic attitude that generates toxic thoughts also makes people more prone to disease and illness. On the other hand, an optimistic attitude promotes a great sense of well being. In short, toxic thoughts can have a toxic effect on the body and put your health at risk. For example, studies on longevity of cancer patients with breast cancer sow that patients with a fighting spirit are more likely to live longer than those who appear to give in and give up (ever documented case of a miracle cure has been accompanied by a positive change in attitude). Furthermore, negative thoughts influence negative actions in what is called the self-filling prophecy. In order for you to raise your self-esteem, you need to change, or reframe, these toxic thoughts. Quite often stubbornness and the comfort of own opinions become obstacles to changing toxic thoughts. Think of how you can change the dialogue in your mind so that you produce fewer toxic thoughts while you are at work in the station or the field. (9) ADOPT A POSITIVE ATTITUDE Reframing is a coping technique that favorably changes stressful attitude to less threatening perceptionon other words, from a negative, self-defeating attitude to a positive attitude. In every moment, you choose your attitude toward life and its challenges. The purpose of reframing is to widen our perspective and focus on the positive aspects of challenging situation. The ability to see ore that what is directly in front of you is not merely a poetic expression. It has been proven that like tunnel vision, your field of vision actually narrows under stress. When your imagination is limited, so too are our possibilities for dealing with the situation. (9)

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Rearming should not be confused with rationalization. Rationalization is an ego defense mechanism that makes excuses, blames others, and shift the responsibility away from yourself toward some or something wise. Reframing allows you to find and adopt a positive mind frame to deal with an unpleasant situation involving your work. Reframing does not deny you the ability to morn, grieve or experience negative thoughts that result from stress. Nor is Reframing an overly optimistic, Pollyanna attitude. It does, however, help you break the cycle of negative thinking that can block the path of resolution. Tools to initiate the Reframing process and dismantle the obstacles include the use of humor, positive affirmation, and creativity One major element of the Reframing process that is designed to bolster self-esteem is the use of positive affirmations. I am confident or I am doing the best I can. Confidence building though positive self-talk can counterbalance the voice of the inner critic, the in your head that constantly tells you that youre just not good enough. (9)

Comic Relief: Humor Therapy People who encounter death and dying on a frequent basis use humor to soften the emotional blow that trauma and tragedy can bring. This type of humor, known as gallows or black humor, is best defined as a humorous look at death. It is important to remember that when a humorous approach is used, it should not be selfdepreciating to lower your own self-esteem. (9) Hobbies Taking your mind off a problem by diverting your attention to an unrelated subject offers your mind a temporary escape from the sensory overload that can perpetuate or produce

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the stress response. Most hobbies, whether they are photography, rock climbing, scuba diving, or fly tying, include some degree of creativity as well as the ability to make order out of chaos on a small and manageable scale. Skills learned while perfecting a hobby can carry over to dealing with work-related issues, as well. (9)

Journal Writing & Art Therapy Both act as a catharsis of pent-up emotions. By allowing these thoughts and feelings to be cleansed from the mind through the expression of writing and art, a foundation is laid to create a better sense of harmony between mind, body, and spirit. (9) Creative Problem Solving Creativity is a means to solve problems and bring resolution to a situation. Creativity is not a gift; it is a human birthright! But like muscles that shrink with disuse, creativity must be regularly exercised to be effective. (9) Dream Therapy Dream therapy is the process of remembering, exploring, and interpreting your dreams. Perhaps of greatest importance to EMS professionals are the dreams that surface as a result of dangerous work situations. Dream therapy involves recalling your dreams and writing down whatever remnants or dream fragments you can recall. You then process the dream information by looking at both the literal and symbolic message. (9) Time Management. Time Wasters: Poor personal boundaries The workaholic

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The procrastinator The perfectionist Organizational Skills: Schedule personal time into each day. Delegate. Schedule interruptions. Access your resources. Learn to recognize your physical and mental limitations. (9)

Communication Skills To be a good communicator, you must not only express your thoughts and feelings into understandable words, but listen, clarify, and understand information as it is intended. Excellent communication skills are important for teamwork, caring for patients, caring for their families, field work, and station responsibilities. (9) Steps to Enhance Communication Skills: 1. Speak with directness. 2. Assume the role of a listener. 3. Maintain eye contact. 4. Avoid word prejudice. 5. Use minimal encouragers. 6. Paraphrase the context of what was said to ensure clarification. 7. Ask questions to improve clarity of statements. 8. Use empathy to reflect and share feelings created by the individual.

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9. Provide personal feedback. 10. Summarize the content of what was said. 11. Enhance your vocabulary. 12. Use language that is appropriate for your listening audience. 13. Attack issues, not people. 14. Avoid putting others on the defensive. 15. Avoid indirect communication. 16. Avoid information overload. 17. Double-check your assumptions. 18. Resolve issues when they arise. (9) Assertiveness Self-assertiveness is described as the ability to be comfortably strong-willed with your thoughts, feelings, and actions; neither inhibited nor aggressive with your actions to the betterment of yourself in your environments. (9) Assertiveness Training Skills Learn to say no. Learn to use I statements. Use eye contact. Use assertive body language. Practice peaceful disagreement. Avoid manipulation. Respond rather than react. (9) Conflict Resolution Skills:

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Even when effective communication skills and the best intentions. There is an abundance of room for misunderstanding and conflict, at work or at home. Ideally, conflicts are best handled when they are resolved right away; however, this is not always possible, such as when a command supervisor instructs you to use a particular procedure you disagree with. Usually, you need some time to organize your thoughts to resolve a conflict effective. Regardless the sooner you respond to a conflict, the better. Several management styles are used to deal with conflict. Not all styles are beneficial, though; some may actually exacerbate the situation. Although not all conflicts will elicit the same response, it is important to recognize your dominant style and make changes where necessary. (9) Conflict Management Styles Withdrawal (negative) Surrender (negative) Hostile aggression (negative) Persuasion (positive) (9) Developing Support Networks A strong social network is now considered a crucial factor in dealing with stress. Having good friend to count on in times of need is a true blessing and can help to buffer the effects of stress. (9)

Relaxation Techniques The primary purpose of relaxation techniques is to interrupt the stress response, specifically through the nervous and hormonal systems. Ultimately, relaxation techniques help to reduce the

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physical symptoms of stress when the body works overtime to keep up with everyday issues, hassles and worries. (9)

Physical relaxation Techniques: Diaphragmatic Breathing, the easiest method of relaxation. It involves the conscious movement of the lower abdomen. It can be used in the midst of acute stress as well as in tense situations to keep calm. (9)

Progressive Muscle Relaxation (PMR). Muscle tension is the number one symptom of stress. PMR involves tensing and relaxing muscles for a short but intense period of time. The tension phase should last for approximately 5 to 10 seconds. The relaxation phase should last for approximately 45 seconds. (9)

Autogenic Training. The term autogenic specifically implies that you have the ability to actually control various body functions like heart rate, blood pressure, and blood flow. Learning how to redirect the mind with suggestions allows you to override the stress response when physical arousal is not the appropriate reaction. Many people use autogenic training to allow various parts of the body to become warm and heavy, which acts like an internal massage, soothing and relaxing the surrounding muscles. (9)

Physical Exercise and Nutrition. For many people, exercise has become the most popular and effective means to reduce stress. With physical exercise, stress hormones released for metabolism in the fight or flight response is used for their intended metabolic purpose.

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Exercise relaxes the mind as well as the body. Exercise acts as a catharsis to release toxic thoughts and feelings as well as burn off stress hormones. (9)

The Nutrition and Stress Relationship When people are stressed, they tend to eat poorly. As a result, the body does not get the essential nutrients it needs, which stresses the body even more. Several substances tend to mimic or start the stress response when eaten, such as caffeine, sugar, salt, and junk food. (9)

Recommendations for Healthy Eating Habits: Eat a well-balanced diet. Eat a good breakfast and space meals evenly throughout the day. Avoid or minimize the consumption of caffeine, sugar, and salt. Eat a diet that provides adequate levels of vitamins and minerals that are vulnerable to stress. Be sure to consume the essential fatty acid Omega #3. Consume an adequate amount of fiber. Take a bioavailable vitamin supplement if necessary. Avoid hydrogenated or partially hydrogenated oils. Minimize your consumption of artificial food products including aspartame. (9)

Music Therapy The type of music that has the greatest relaxation effect is instrumental music. Music has an influence on the nervous system and can used as a means to promote mindbody-spirit homeostasis when the need arises. (9)

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Other Relaxation Techniques Tai chi (and other martial arts) Hatha yoga Biofeedback Body work (massage therapy) (9)

Mental Relaxation; Meditation. Meditation the oldest recognized relaxation technique known to all civilizations. Research findings reveal those people who meditate regularly show less anxiety, decreased smoking, decreased alcohol and recreational drug use, greater sense of self-esteem, greater sense of self-confidence and self-reliance, and better quality sleep. The American Heart Association now advocates meditation as a way to help prevent coronary heart disease. (9)

Mental Imagery. Mental imagery is daydreaming with the sole purpose of relaxing. It is a technique to access the powers of the conscious and unconscious mind to create a pictorial panorama that suggests calmness and tranquility, much like taking a vacation. It can be used as a healing tool to restore health to body organs caught in a state of dysfunction and disease (like cancer) and imagining those organs in a healthy state. (9)

The Big Picture Stress is a part of life, but it doesnt have to be the focus of your life. To deal with stress effectively, you need to cultivate your inner resources, which include patience,

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confidence, intuition, creativity, a sense of humor, courage, optimism, self-reliance, compassion, and faith. Good stress management skills require a balancing act of honoring your own well being (in mind, body, and spirit) just as you honor those you are called to serve or assist. Focusing on yourself is not always easy, but you must make the time to nurture your own needs. The death of a colleague can act as a catalyst for this thought process, but it doesnt have to be, nor should it be the only time for reflection. The greatest percentage of work-related stressors are based on the issue of control. In many cases, you expend much time and personal energy trying to influence and manipulate things over which you have no control, such as people, policies, agencies, etc. (9)

Tips for Reducing Stress: 1. Learn to respond rather than react to situations, which you find upsetting, or a violation of your rights as an individual. 2. Learn to refine your expectations and build a healthy tolerance toward situations that often disturb your inner balance. 3. Randomly give yourself positive feedback by way of daily affirmations to validate your own self-esteem and worthiness. 4. Make a habit to get out and exercise to burn off any residual stress hormones which may be circulating in your body from a stressful day on the job. 5. Balance your scale of emotions with some comic relief by incorporating some humor and mirth into your daily routine. 6. Nurture the connectedness of those people in your circle of co-workers, friends, and family.

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7. Diversify your interests and activities so that your whole identity is not wrapped up in your career or paycheck. 8. Learn to recognize and become comfortable with all your emotions, spanning the spectrum from anger to love, and learn to express these feelings creatively and productively. 9. Exercise your sense of creativity and use this talent as well as other inner resources to relieve stress on the job, as well as at home. 10. Learn to resolve issues and concerns with others when they arise through peaceful and diplomatic confrontation rather than avoidance. 11. Take short breaks in the course of each working day to relax and give your body a chance to return to a normal resting state of homeostasis. 12. Make it a habit every day to dedicate personal time for you without feeling guilty. Start with as little as 5 minutes and build up from there. (9)

Procedures and Population In Detroit, the Emergency Medical Services Division is placed within the Fire Department. Firefighters are not trained as first responders for medical emergencies. Currently, 202 paramedics, 8 specialists, and 105 emergency medical technicians are deployed from 25 medic units. They respond to over 128,000 runs annually, serving a city of 950,000 people spread over 139 square miles.

In the present study, EMS workers in the Detroit Fire Department were surveyed to identify their perceived job stressors and measure degree of job related stress. Survey forms were distributed

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to 120 EMS workers on two shifts in one twenty-four (24) hour period. Fifty (50) surveys were returned (40% return rate). The ten (10) items, self-administered instrument used is shown in the Appendix. Five (5) of the surveys returned were incomplete, or contained non-responsive answers and were not included in the study. One (1) respondent reported training at the Specialist level and was also not included in the study. Of the forty-four (44) remaining respondents thirty-eight (38) were male, six (6) female. The average age of study subjects was 37 years (range 23-54). Twenty-five (25) reported that they were not married at the time of the survey. Seventeen (17) were trained as Emergency Medical Technicians (Basic Level) and twenty-seven (27) as Paramedics (Advanced). The average years of experience with Detroit EMS was eight (8), but experience was quite varied ranging from two (2) months to thirty-one (31) years. Thirty-six (36) reported previous experience with another emergency service company. Data were stratified by experience (Table 2).

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Table 1. Summary of study subject demographics Number of Study Subjects 44 Age in Years (mean) (range) Gender (male) (female) Training Level (Basic) 37 23 - 54 86% 14% 39% 61% Years Detroit EMS (mean) (range) Previous EMS Experience Marital Status (single) (married) 8 <1 - 31 82% 57% 43% Table 2. Summary of time on the job Years Detroit EMS <5 5-9 10-19 20+ No. Subjects 15 12 14 3 % Subjects 34 27 31 7

Survey Results The average total score for all subjects was 51.4, which indicate a high level of stress. Statements 2, 4, 6, and 7 elicited response scores averaging more than the mid-point score of 5 (Table 3).

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Table 3. Mean responses by stress indicator. STATEMENT NUMBER 1 2 3 4 5 6 7 8 9 10 Total Mean Responses All Questions

STRESSOR

MEAN SCORE 4.9 6.2 3.5 8.0 2.8 6.8 6.7 3.8 3.0 3.8 51.4

At work, I cant say what I really think or get things off my chest. My job has a lot of responsibilities, but dont have much authority or autonomy (or I have too much) I tend to spend more time at work than I would like. I seldom receive adequate acknowledgement or appreciation when my work is really good or I have performed well. In general, Im not particularly proud of my job or satisfied with my job. I dont feel that I am adequately compensated for the work I do. My workplace environment is not very pleasant or particularly safe. My job interferes with my family, social obligations and personal needs. I tend to have frequent run-ins with my supervisors, co-workers, or clients/patients or others (e.g., media personnel, ambulance chasers). Most of the time, I feel that I have little control over my life at work.

While 11% of respondents were in the low stress category, fully 79% were in the moderate and high stress categories. 9% were in the very high stress category (Table 4). Professional counseling is recommended for individuals at this level (9). Table 4. Total Score by stress level category SCORE 10-29 30-50 51-75 76-100 LEVEL Low job stress (Maintain current coping methods) Moderate job stress (Coping skills and relaxation techniques encouraged) High job stress (Coping skills and relaxation techniques encouraged) Very high job stress (Professional counseling NO. % RESPONDENTS RESPONDENTS 5 11 20 15 4 45 34 9

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recommended) Detroit EMS workers appear to see a disconnect between their level of responsibility and their level of authority. Their responses to statement 2 [My job has a lot of responsibilities, but I dont have much authority or autonomy (or I have too much)], is 6.2, above the mid-point on the response scale (Table 3). Because their responses to statement 10 (Most of the time, I feel that I have little control over my life at work.) are relatively low with a mean of 3.2 (Table 3), it does not appear that too much responsibility is the issue. Mean responses to this statement increase with time on the job except for those with 20+ years (see Table 5). Table 5. Mean responses by years with Detroit EMS and presence of previous experience Stressor 2: My job has a lot of responsibilities, but I dont have much authority or autonomy (or I have too much) YEARS DETROIT THOSE WITH PRESENCE NO PREVIOUS ALL EMS PREVIOUS EXPERIENCE EMS EXPERIENCE RESPONDERS <5 5.1 5.0 5.1 5-9 10-19 20+ 6.9 6.8 10 3.3 2.5 5.0 6.1 6.5 5.0

Of the job stressors studied, lack of appreciation for the job done scored highest with a mean of 8.0 on the 10 point scale (Table 2). These scores tend to increase with time on the job, but this does not hold for those with 20+ years on the job (Table 6). Table 6. Mean responses by years with Detroit EMS and presence of previous experience Stressor 4: I seldom receive adequate acknowledgement or appreciation when my work is really good or I have performed well. YEARS DETROIT EMS <5 5-9 10-19 20+ THOSE WITH PRESENCE PREVIOUS EXPERIENCE 6.9 7.7 9.1 7.5 NO PREVIOUS EMS EXPERIENCE 7.0 8.7 9.3 10 ALL RESPONDERS 6.9 7.9 9.1 8.3

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Compensation seems to be an important issue among Detroit EMS workers in all categories of time on the job (Table 7). Compensation received a mean score of 6.8, which is above the mid-point on the scale. Table 7. Mean responses by years with Detroit EMS and presence of previous experience Stressor 6: I dont feel that I am adequately compensated for the work I do. YEARS DETROIT EMS <5 5-9 10-19 20+ PRESENCE PREVIOUS EXPERIENCE 5.4 4.3 6.5 9.0 NO PREVIOUS EMS EXPERIENCE 9 8.7 7.8 10 ALL RESPONDERS 5.6 5.5 6.9 9.3

n 14 9 11 2

n 1 3 3 1

As expected in a big city, Detroit EMS workers consider safety to be an issue for them. Their mean overall response to the statement, My workplace environment is not very pleasant or particularly safe. is 6.2 Table 2), which is above the mid-point on the response scale. Again, scores increased with time on the job (Table 8). Table 8. Mean responses by years with Detroit EMS and presence of previous experience Stressor 7: My workplace environment is not very pleasant or particularly safe. YEARS DETROIT EMS <5 5-9 10-19 20+ PRESENCE PREVIOUS EXPERIENCE 5.9 6.2 7.3 7.6 NO PREVIOUS ALL RESPONDERS EMS EXPERIENCE 1.0 5.0 5.5 8.7 10 6.1 8.3 8.2

Discussion and Implications In this survey, Detroit EMS workers scored high on two of these (Statements 2 and 4) which reflect conditions that could be changed by management without any additional expense to the

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operation. These were My job has a lot of responsibilities, but dont have much authority or autonomy (or I have too much), and I seldom receive adequate acknowledgement or appreciation when my work is really good or I have performed well. Because workers did not score statement 10 especially high (mean score of 3.8 for Most of the time, I feel that I have little control over my life at work.), the conclusion here is that workers are citing a problem is too much responsibility with too little authority rather than too much authority.

It also appears that the current techniques used for recognizing quality work (annual awards presentations) are not adequate to meet the needs of workers in this area. Lack of acknowledgement received the highest mean score (8.0 on a 10 point scale) indicating an area for high levels of resentment, which might affect job performance. Simple methods (such as regular compliments from supervisors) are available to address this type of work issue.

For several years, it has been the Citys practice to hire paramedics with experience at salaries above entry level. Those with considerable experience may even be hired at the maximum pay for the job. The vast majority of workers at all levels of seniority indicated previous EMS experience (Table 6), suggesting that they left other jobs to work in Detroit EMS. In spite of that compensation received a mean score of 6.8, which is above the mid-point on the scale. Mean scores for this response increased with time on the job. Possible explanations for this include dissatisfaction with the new practice of hiring at the maximum pay (v. awarding increases with time on the job) and failure of management to increase maximum pay rates over time to reflect market.

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Recommendations Based on this survey, Detroit EMS should consider the following: o Developing a proactive stress management program to assist the personnel with their stress management requirements. Research has shown that EMS personnel are much more productive when they manage their stress constructively. o Additional training, supervision, or technical support for EMS workers who believe that their level of responsibility exceeds their authority to deal with work situations; o Development of additional techniques for more frequently acknowledging good work performance; o Review of salaries to establish whether they are within the market range with that information being shared with EMS workers; o Working with the Detroit Police Department to deliver crime prevention and personal safety training to EMS workers; o Improving the aesthetics of EMS field facilities and headquarters; and o Establishing a stress proactive management program designed to address other personal and job stressors experienced by EMS workers on a daily basis.

In addition to the employers input, the EMS field personnel needs to have a thorough understanding of stress and how to manage it with or without a structured Stress Management Program in place

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Appendix Survey Tool (side 1)

This survey is being done to comply with the requirements for a research paper, but also to obtain information to start a stress management program for E.M.S. Please complete survey and give to your supervisor. These additional items have been added to the survey: Male___________ Age ___________ Basic______________ Paramedic_______________ Female____________

Length of service _____________________ Single ________________ Married ___________________

Had additional prior experience with another Service _________________________

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Survey tool taken from Figure 1. Survey Tool (side 2)

Managing Stress in Emergency Medical Services by Brian Luke Seaward, Ph.D.

Work Stress Survey The following personal and confidential assessment is adapted from the American Institute of Stress. It is designed to help you determine your own level of workplace stress. Please take a few minutes to rank each of the 10 questions on a sliding scale from 1 to 10 as shown. Then total your score and decide whether you agree with the results. 1 = strongly disagree with the statement 5 = neither agree nor disagree with the statement 10 = strongly agree with the statement _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ ____ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. At work, I cant say what I really think or get things off my chest. My job has a lot of responsibilities, but dont have much authority or autonomy (or I have too much) I tend to spend more time at work than I would like. I seldom receive adequate acknowledgement or appreciation when my work is really good or I have performed well. In general, Im not particularly proud of my job or satisfied with my job. I dont feel that I am adequately compensated for the work I do. My workplace environment is not very pleasant or particularly safe. My job interferes with my family, social obligations and personal needs. I tend to have frequent run-ins with my supervisors, co-workers, or clients/patients or others (e.g., media personnel, ambulance chasers). Most of the time, I feel that I have little control over my life at work.

Please add up the number you gave each question. Total your job stress score.

Legend for your job stress score: 10-29 Low job stress (Maintain current coping methods) 30-50 51-75 76-100 Moderate job stress (Coping skills and relaxation techniques encouraged) High job stress (Coping skills and relaxation techniques encouraged)

Very high job stress (Professional counseling recommended)

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Source: Adapted from Job Stress Before it Reduces You. Health and Safety, November 1992, pages 40-43.

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Endnotes 1. Demers, Joel. PLEASE READA Sad Reminder (1 of 4). Online posting, 12 July 1998. Smith, Dave. Stress Assessment Questionnaire. 24 Jan. 2003. <http://www.MySkillsProfile.com> Carpi, John. A Smorgasbord of Stress-Stoppers. Jan-Feb 1996. <http://www.questia.com/ PM.qst?action=print&docId=50003129129&pgNum=1> Beaton, Randall, et al. Social Support and Network conflict in firefighters and paramedics. Western Journal of Nursing June 1997. Brown, Roxanne. How People Cope with Stress. July 1990. <http://www.questia.com/PM.qst?action=print&docId=5000123020&pgNum=1> Goldfarb, Bruce. Under Pressure: A Rash of Suicides and Sudden Deaths Among New York City EMS Workers is Raising Fears of Rescue-worker Burnout. Online posting. 16 Nov. 1992. Soothing Strategies to Reduce Stress. May 1994. <http://www.questia.com/PM.qst?action=getPage&docId=5000210466&now+1060684 1484&> Crampton, Suzanne, et al. Stress and Stress Management. 1995. <http://www.questia.com/PM.qst?action=print&docId=5000363883&pgNum=1> Seaward, Brian Luke . Managing Stress in Emergency Medical Services. New York: Jones and Bartlett, 2000.

2.

3.

4.

5.

6.

7.

8.

9.

10

Tangherlini, Timothy. Heroes and Lies: Storytelling Tactics Among Paramedics. 2000. <http://www.questia.com/PM.qst?action=print&docId=5001747029&pgNum=1> Sherman, Carl. Inquiries Heighten Stress for Emergency Workers. (Firefighters, Police, Paramedics). Online posting Dec 2001.

11.

12.

Health Services at Columbia. Health Town Hall Meetings that Matter. <http//www.health.Columbia.edu/hrs/events/healthLIVE-suicide-audio.html> McMahan, Frank. Paramedics and Burnout: Coping and Prevention Suggestions. Online posting.

13.

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14.

Boudreaux, Edwin, et al. Stress, Job Satisfaction, Coping, and Psychological Distress Among Emergency Medical Technicians.. 1997.

15. Grevin, Francine. Posttraumatic Stress Disorder, Ego Defense Mechanisms, and Empathy Among Urban Paramedics. Psychological Reports, 1996. 16. Scheets, Gary. Medics Risk Own Lives to Try to Save Others. Dec 1996. <http://www.questia.com?PM.qst?action=print&docId=5001715540&pgNum=1> 17. Jamner, Larry, and Goldstein, Iris. Ambulatory Blood Pressure and Heart Rate in Paramedics: Effects of Cynical Hostility and Defensiveness. Psychosomatic Medicine, 1991. 18. Erich, John. Howling at the Moon: Violent Patients Taking It Out on EMS. Oct 2001 <http://www.emsmagazine.com/issues/violenceinems.html> 19. Catterall, M., Dean, G. Causes, Effects, and Management of Stress in Paramedics. Emergency Medical Journal. Online posting Jan 2003. 20. Morgan, Cara and Massam, Margaret. An Evaluation of Humour in Emergency Work. The Australasian Journal of Disaster and Trauma Studies. <http://www.massey.ac.nz/trauma/issues/1997-3/moran1.html> Autogenic Training. Online posting. <http://www.stresslessems.com/student/autogenic.html>

21.

22. A Holistic Approach to Stress Management. Online posting. <http://www.stresslessems.com/instructor/holistic.html> 23. Some More Insights on Stress and Disease. Online posting <http://www.stresslessems.com/instructor/mindbody.html> 24. Boudreaux, Edwin, and Mandry, Chris. The Effects of Stressors on Emergency Medical Technicians (Part II): A Critical Review of the Literature, and a Call for Further Research. Prehospital and Disaster Medicine. October-December, 1996. 25. CE Solutions EMS Continuing Education. Stress Management. Online posting. <http://www.ems-ce.com/newcode/readart> 26. Scala, William. Programs to Protect Emergency Personnel Police, Fire, & EMS. Online publication 1999. <http://www.paramedic.com/artic.e_view.asp?cid=2233>

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