Stress and Emergency Healthcare Workers 1
Running Head: The Relationship between Stress and Emergency Healthcare Workers
Stress in Emergency Healthcare Workers
Tim Standon
University of La Verne
October 28, 2009
Senior Thesis Advisor – Kimberly Porter Martin
Everyone everywhere is affected to some degree by the stresses and strains of daily life. However, there are some in society who work and live under extraordinarily stressful conditions. Professions like the military, air traffic control, and emergency services are innately high stress work environments. The people who do these jobs must cope not only with the stresses that affect everyone in society on a day-to-day basis, but also the pressure to accomplish miracles through their work, followed by the stress of actually trying to doing it.
The actual numbers of emergency workers is difficult to pin down due to the size, diversity, and overlapping nature of the field. In the United States there are several agencies that represent different factions of emergency personnel. The National Registry of Emergency of Emergency Medical Technicians (NREMT) claims that there are over 1,000,000 active paramedics and EMT’s (National Registry of Emergency Medical Technicians, 2009). The US Department of Labor states that as of 2006 throughout the United States there were approximately 361,000 paid firefighting jobs, about 201,000 paid EMT and paramedic positions, and nearly 861,000 paid police officers. They also state that there are approximately 2,505,000 registered nurses and 633,000 doctors (United States Department of Labor, 2009). These statistics do not include any of the volunteer positions or other related paid jobs within the different areas of emergency care.
Stress
Stress is a word that is commonly used but is often not well understood. Kagan, Kagan , and Watson (1995) define stress as a basic reaction experienced by all living organisms, that it is due to the tension that results from one’s basic vulnerability to the surroundings, to one’s own circumstance, to one’s own impulses or needs, and to one’s reliance on others. They further explain that stress is expressed emotionally, cognitively, and behaviorally: and that one’s reaction to stress under different situations is determined by one’s underlying personality, prior experience, and coping mechanisms. It is also suggested that people may not be fully aware of their stressors under all conditions, and that stress often is an out-of-awareness thing that happens (Kagan et al., 1995). Signs of excessive levels of stress can often be noticed by observers before they are noticed by the affected person. Stress, oddly enough, is different things to different people and even different things to the same person at different times (Kagan et al., 1995).
A stressor can be defined as any stimulus that causes a stress response from an individual which taxes their physiological or psychological resources and possibly elicits a subjective physical or mental strain (Anisman & Merali, 1999). Stressors can be physical and/or psychological. The response from stressors manifests in physical and psychological ways. Some of the problems associated with being under stress are: a higher incidence of alcohol and drug usage, increased risk for cardiovascular problems like hypertension (high blood pressure) and myocardial infarction (heart attack), increased risk of stroke, and insomnia as well as other sleep disorders (Anderson, 2009).
Physical Manifestations of Stress
According to Beaton, Murphy, Johnson, Pike, and Jarrett (1995), the International Association of Firefighters (IAFF) claims that firefighting is one of the United State’s most dangerous professions. The 1990 US Department of Labor statistics show that firefighters are 9.2 times more likely to be injured and 4 times more likely to be killed on the job compared to workers in private industry. In 1992 the IAFF revealed that the single most relevant cause of line-of-duty death is cardiovascular disease that leads to death by stroke and cardiac arrest. This is surprising when one takes into account how cardiovascularly fit firefighters are (Beaton et al., 1995).
Police and other Public Safety Officers have shown an increase in cardiovascular disease as compared to others in society. After a 22 year follow up in a longitudinal study of 970 Helsinki police officers, there was an association found between hyperinsulinemia and increased heart disease independent from other risk factors. A study of Buffalo, New York police officers was done to see if there was a difference in cardiovascular disease markers between mildly or sub-clinically stressed and highly stressed officers. The study showed that there was a decrease in coronary blood flow as officers’ stress levels increased from mild to moderate to severely stressed. The dilation of the vessels was nearly half that in severely stressed officers compared to sub-clinically stressed officers. The study suggests that failure to turn off the stress mediator chemicals of the body, such as cortisol, will cause an individual to continue to have high levels of stress which will eventually generate wear and tear on the body and lead to disease (Violanti et al., 2006).
Post Traumatic Stress Disorder
Post-traumatic stress disorder or PTSD, as defined by Anderson (2007), is an anxiety disorder which can build from an exposure to a frightening event or ordeal in which serious physical harm occurred or was threatened (Anderson, 2007). Robbers and Jenkins (2005) state that PTSD is also known as shell shock or battle fatigue. They continue on to state that this disorder can overpower an individual and become incapacitating by inducing symptoms such as panic, defenselessness, and avoidance. Frightening thoughts or memories of the critical stimuli can also invoke numbness, fatigue, aggression, rage, or hyper vigilance (Robbers &Jenkins, 2005). According to Anderson (2007), the National Institute of Mental Health has found that traumatic events may trigger PTSD. Some of these events include violent personal assaults, natural or human-caused disasters, accidents, or military combat. People with PTSD have persistent frightening thoughts and memories of their traumatic event, they have an emotional void, and are frequently unable to relate normally with others. This is especially true for relationships with people to whom they were once close. Furthermore, they may experience sleep problems such as insomnia or night terrors, and they can be easily startled at any time (Anderson, 2007).
A study of women at a long-term treatment center in the USA, which was reported by Brewerton (2008), shows a possible link between PTSD and eating disorders. The strongest correlation between PTSD and eating disorders occurred in patients with anorexia nervosa which is a binge-eating/purging type of disorder.
“It has been hypothesized that eating disordered behaviors, particularly purging behaviors, serve to facilitate avoidance of traumatic material and to numb the hyper-arousal and emotional pain associated with traumatic memories and thoughts. Purging may also promote forgetting parts or all of a traumatic event, for example: dissociative amnesia. Several studies have reported higher rates of dissociative symptoms in bulimic patients than in controls, and in the National Women's Study, 27% of patients with bulimia nervosa reported forgetting all or part of traumatic memories compared with 11% of participants who did not have an eating disorder. Thus, bulimia often serves as a maladaptive coping strategy in the same way substance abuse does in relationship to trauma and PTSD” (Brewerton, 2008:2-3).
A prime example of an incident that caused PTSD in EMS workers is from the September 11, 2001 terrorist attack on the USA. There was a huge loss of innocent life, along with the loss of life of colleagues and even family members of the EMS workers on that fateful day, not to mention the loss of life and the chronic illness associated with working at ground zero of the World Trade Center in New York. Many individuals in the first responding teams who were not killed in the collapse have suffered long lasting medical problems from breathing polluted air and being exposed to toxic substances while at the scene. Some of their primary medical complaints are from upper and lower airway problems as well as esophageal problems. They put in long, physically and emotionally draining days digging out a few survivors, but mainly finding those who were deceased. This led some workers to develop PTSD (Herbert et al., 2006).
Another example of emergency workers developing PTSD can be found in 2004. Robbers and Jenkins did a study regarding PTSD symptoms on the Arlington County police officers that responded to the September 11, 2001 terrorist attack of the Pentagon. The all of the sample population had responded to the incident within 90 minutes of the attack. The officers worked an average of 136 hours at the site. Some of the officers did not return to their homes for several weeks, because they felt a need to stay on the site in order to clean up and restore the Pentagon. Initially the officers assisted the fire department in rescue operations and also controlled traffic in the immediate area of the Pentagon. Later, the police officers became part of the teams that sifted through the rubble, searching for body parts, personal effects, airplane parts, and top secret information. Many of the officers came in contact with what they were looking for. One experienced officer reported that after finding charred human remains, the thing that troubled him the most was the unearthing of a small, pink child’s purse. Another officer said that a burnt teddy bear was the most unforgettable picture left in his mind. The study found that more than one third of these individuals had suffered from some symptoms of PTSD over the three year time period. The research suggests that higher levels of PTSD may be found in police officers due to the experience of disenfranchised grief after exposure to traumatic events, because officers who experience emotional trauma are not socially sanctioned to grieve. Furthermore, the increase in PTSD may also be related to police organization and management. The police organization is para-militaristic; its officers are required to be the helpers, not the helped. Basically the police are supposed to be in control and they are held to higher moral standards by the community. And finally, it is suggested that the police officers code of silence adds to the development of PTSD, because many officers think that a cop who seeks mental health treatment is weak and not reliable (Robbers & Jenkins, 2005).
Secondary Traumatic Stress
A related form of PTSD is referred to as secondary traumatic stress or STS for short. It can be described as a healthcare worker being traumatized while trying to help someone with PTSD by listening to their stories. This has occurred with mental health professionals who work large incidents, like the September 11th tragedy. In the September 11th instance, social workers were exposed to the same event as those whom they were trying to help. For many of the counselors, hearing the clients' stories interacted with their own stress levels and concerns about the terrorist attacks, heightening the resultant STS reaction beyond the simple additive effects of the two factors taken alone (Pulido, 2007).
Other professionals such as firefighters, paramedics, police officers, and 911 Dispatchers can also experience STS from helping and wanting to help people who are victims of trauma. It is suggested that repetitive exposures to critical incidents can lead to problems from the cumulative effects of those exposures. Exposure to duty-related trauma or critical incidents usually involves overwhelming exposure to injured, mutilated, or dead and dying victims (Beaton, Murphy, Pike, & Corneil, 1998).
Burnout
Burnout is another concept that goes hand in hand with stress and PTSD. Committed professionals who start out their careers with energy, efficiency, and dedication to what they are doing can end up exhausted, inefficient, and cynical. Burnout is characterized as having feelings of failure, being worn out or becoming exhausted by excessive demands of the job. Burnout manifests both physically and behaviorally causing emotional and physical exhaustion, diminished caring, and a profound sense of demoralization (Bush, 2009). Cannon (2006) states that the American College of Emergency Physicians lists the symptoms of burnout as: withdrawal from family then friends, denial, overwork, anxiety, dread, anger, isolation, martyrdom, risk taking, and depression even leading to suicide (Cannon, 2006). As reported by Anderson (2008), a study of 119 nurses in the Caribbean was done on work-related depression. They looked at the nurses’ role, their work and social factors, stress, burnout, depression, absenteeism, and turnover intention. The researchers found that burnout was the sole predictor of depression, which directly predicted both absenteeism and turnover intention (Anderson, 2008).
A 2005 study of Taiwanese firefighters, suggests that major life stressors often leads to depression and a decrease in the quality of life for an individual experiencing them. The article goes on to propose that those individuals with a poor quality of life often will not return to work. A finding of the study, done by the Taiwan Department of Health, showed a connection between depression and suicide; and as a result of that finding, high risk groups such as firefighters are being encouraged to receive mental health screenings as an attempt to reduce suicides (Chen et al., 2007).
A survey study of nurses in Finland was done in 2001-2002 to see if there was an association between nursing management behavior and burnout among nursing personnel in health care. Six-hundred-twenty-seven nurses were randomly selected from a frame of 900 Finnish nurses, most of them women, in different patient contact practices. They found small correlations between leadership styles in the organization and burnout in nurses. Style of leadership is both positively and negatively associated with burnout among nurses. A Nurse Manager who has an active and future-oriented transformational leadership style will have fewer nurses working under him/her who experience burnout. This management style tends to protect employees from emotional exhaustion, depersonalization, and to increase feelings of personal accomplishment. On the other hand, nurse managers who use a passive leadership style are setting the employees up for burnout. Subordinates working under this kind of leader are particularly vulnerable to emotional exhaustion and depersonalization. The information obtained from this study suggests that the management team must be aware that their actions as well as their omissions are powerful and can make the difference between an emotionally healthy workforce and an emotionally unhealthy one (Kanste, 2008).