Abstract
This study examined the association between symptoms of posttraumatic stress, coping styles, and subjective and biological responses in paramedics confronted with a simulated high-acuity event. Twenty-two advanced-care paramedics participated in a high-stress-simulated clinical scenario using a computerized human patient simulator. The Coping Inventory for Stressful Situations and the Impact of Event Scale–Revised were administered prior to participation in the scenario to ascertain preexisting coping styles and posttraumatic stress. Subjective anxiety, as measured by the State-Trait Anxiety Inventory, and acute physiological stress as measured by salivary cortisol levels, were assessed at baseline, and in response to the scenario. Results revealed that posttraumatic stress was not associated with biological or subjective indicators of stress. This suggests that high levels of posttraumatic stress among paramedics do not place them at increased risk of distress during high-stress clinical situations. Acute anxiety and physiological stress responses to the clinical scenarios were associated with the coping styles of individuals. Coping strategies are potentially modifiable and should be the consideration of future research and interventions.
In a program of research that has spanned more than a decade, we have been working to understand the incidence and nature of trauma response in paramedics and factors that influence response to trauma. Our initial research involved a survey of paramedics in a large urban centre (Regehr, Goldberg, Glancy, & Knott, 2002) that revealed high levels of trauma exposure and subsequent distress in paramedics. All participants indicated that they had been exposed to multiple critical events on the job. As a result of the exposure, 29% of the sample indicated that they had symptoms of posttraumatic stress disorder (PTSD) in the high or severe range; 29.1% indicated that they had taken mental health stress leave following a critical event; 11.6% reported alcohol abuse following a critical event compared with 1.2% before event; and 9.3% reported the use of psychiatric medication (Regehr, Goldberg, & Hughes, 2002).
These findings are consistent with previous research on paramedics that reports high rates of exposure to traumatic and gruesome events and symptoms consistent with PTSD in 20% to 30% of paramedics (Alexander & Klein, 2001; Clohessy & Ehlers, 1999; Grevin, 1996). In other research comparing high-demand occupations, paramedics rank first in terms of negative impacts on physical health, fourth in terms of negative impacts on psychological well-being, and second in terms of low job satisfaction (Johnson et al., 2005) and have the highest reported mean burnout score for any group of health professionals (Grigsby & McKnew, 1988).
In subsequent qualitative research, paramedics expanded on these themes, revealing in vivid detail the impact of trauma exposure on the lives of paramedics and their families (Regehr & Bober, 2005; Regehr et al., 2002). Workers exposed to traumatic events reported feeling disengaged and emotionally distant from family members; expressing generalized anger and irritability toward family; and generalized fears for the safety of family members that resulted in a tendency to become overprotective (Regehr et al., 2002). Qualitative interviews with 14 spouses of paramedics (Regehr, 2005) confirmed the impressions of emergency responders and identified family struggles with managing everyday job stress and dealing with the paramedic’s emotional reactivity and emotional withdrawal following trauma exposure.
Thus, it is clear that paramedics are regularly exposed to stressful and traumatic situations and as a result suffer mental health, emotional, and social consequences. What is less evident is the impact of traumatic stress symptoms on paramedics’ responses to acute stress situations. Acute stress can be understood to be both a psychological and a physiological experience. From a psychological perspective, when the demands of any given situation are assessed as outweighing the resources of the individual, the situation will be assessed as a threat to individual well-being and the response will be emotional distress or anxiety (Weiss, Marmar, Metzler, & Ronfeldt, 1995). From a physiological perspective, activation of the hypothalamic–pituitary–adrenal (HPA) axis accompanies a sympathetic nervous system response and results in increased cortisol release into the blood, urine, and saliva (Kemeny, 2003; Neylan et al., 2004; Otte et al., 2005). Previous research has demonstrated an association between cortical suppression and both prior trauma exposure (Shea, Walsh, MacMillan, & Steiner, 2004; Yehuda, 2002) and ongoing traumatic symptoms (Neylan et al., 2004; Yehuda, 2002). That is, previous trauma exposure and trauma symptoms appear to impair adaptive responses during acute stress.
The association between trauma exposure and response and acute stress is vital in the emergency services, considering growing evidence that performance is impaired when individuals facing high demands exhibit elevated stress responses (Dickerson & Kemeny, 2004). For instance, paramedics exposed to high-stress events show impairments in the ability to calculate drug dosages, to provide cardiac resuscitation, and to recall pertinent details from clinical scenarios (LeBlanc, MacDonald, McArthur, King, & Lepine, 2005; LeBlanc, Tavares, King, Scott, & Macdonald, 2010). This is consistent with a growing body of research in the psychology domain showing that individuals who exhibit a stress response to experimental stress manipulations, in particular the activation of the HPA axis and ensuing elevation in cortisol levels, are more likely to exhibit impairments on tasks of memory and attention (LeBlanc, 2009).
A potentially important mediating factor in posttraumatic stress and acute stress response is an individual’s coping style: The thoughts and behaviors used to manage the demands of situations that are appraised as stressful (Endler & Parker, 1994). Although there are discrepancies with regard to the particular organization of various types of coping styles, they are often divided into the categories of task oriented, emotion oriented, or avoidant oriented (Endler & Parker, 1994; Folkman & Moskowitz, 2004). Task-oriented coping includes attempts to modify or eliminate the sources of stress through action. Emotion-oriented coping includes behavioral and cognitive responses primarily aimed at managing emotional reactions to a stressor and maintaining emotional equilibrium. Avoidant-oriented coping involves attempts to actively avoid confronting the problem or engaging in behaviors aimed at avoiding emotional tension, such as overeating or alcohol use (Billings & Moos, 1981).
Coping style is reported to be a mediating factor between job stress and job satisfaction in management-level police personnel (Cooper, Kirkcaldy, & Brown, 1994). Furthermore, studies of emergency responders and armed forces personnel exposed to traumatic events have found an association between negative coping styles and psychological stress (Bramsen, Dirkzwager, & van der Ploeg, 2000; Fortes-Ferreira, Peiro, Gonzalez-Morales, & Martin, 2006; Shakespeare-Finch, Gow, & Smith, 2005; Waysman, Schwarzwald, & Solomon, 2001). In previous work with firefighters and police officers, the use of emotion and avoidant coping styles following exposure to a traumatic event have been associated with the development of posttraumatic stress.
The goal of this study was to examine the association between posttraumatic stress, and subjective and biological responses in paramedics confronted with a simulated high-acuity event. Furthermore, we were interested in understanding the association between coping strategies and posttraumatic stress and acute stress.
Method
Participants
Twenty-two advanced care paramedics, 17 men and 5 women, from regional land and air ambulance services in Canada took part in the study. Advanced care paramedics function within nationally defined core competencies (Paramedic Association of Canada, 2001); perform delegated medical acts, such as electrocardiogram (ECG) acquisition and interpretation, and advanced life-support procedures, such as tracheal intubation; and administer emergency medications that require dosage calculations. Participants were required to refrain from strenuous exercise, smoking, drinking caffeinated or low-pH beverages, and eating for at least 1 hr before participation. Paramedics with known endocrine diseases or on corticosteroids were excluded from the study.
This study was approved by the Health Sciences Research Ethics Board of the University of Toronto. All participants were advised that if they were experiencing high levels of stress, resources would be made available to them.
Study Design
For the purpose of this study, the high-acuity event was created with the use of a high-fidelity mannequin placed in an ambulance simulator. Given that it is impossible to predict and is unethical to manipulate acute events in the real world, high-fidelity simulation provided an invaluable method to recreate realistic stressful work-related situations and to observe responses of emergency workers.
Step 1—Baseline tests: Baseline salivary cortisol and subjective anxiety were obtained prior to the stress-inducing scenario. Participants also completed a series of questionnaires targeting demographic data, coping styles, and posttraumatic stress.
Step 2—Simulation of a stressful encounter in prehospital care: The paramedics were required to manage a 50-year-old cardiac patient complaining of chest pain. To create a high-acuity situation, several stressors were added to the scenario. Auditory noise was introduced by setting the volume and alarms on monitors at maximum and by having constant two-way radio communication noise. A socioevaluative stressor was introduced by an actor playing the role of patient’s partner, who was visibly distressed and challenging the participants’ actions and decisions. The actor’s role was carefully scripted not to directly interfere with patient care or the patient. Throughout the scenario, the participants were assisted by a confederate paramedic who was instructed to respond to any request for assistance but not to take the lead in any decision making or interventions. This closely approximates clinical practice situations in which advanced-care paramedic would be working with a partner who possesses a different scope of practice. Patient presentation and treatment expectations for the scenario were developed by consensus with four experts in the field of prehospital care.
Step 3—Postscenario reactions: The State-Trait Anxiety Inventory (STAI) was administered immediately following the scenario. Salivary cortisol samples were obtained 20 min and 30 min after the start of the scenario, as levels have been shown to peak 20 to 40 min following the onset of an acute stressor (Kemeny, 2003).
Materials
Human-patient simulator
An adult-sized computerized mannequin (Medical Education Technologies Inc. [METI], Sarasota, FL) was placed in a recreated ambulance environment. The recreated ambulance environment was identical in functionality, equipment, and dimensions to real ambulances. The METI mannequin can be programmed to replicate many human physiological functions such as heart rate, pulse in the limbs, and breath sounds, simulating a wide variety of medical conditions. The scenarios were controlled from outside of the simulated ambulance to facilitate immersion into the scenario by the paramedics. The paramedics could communicate with the control room using a two-way communication system. A closed-circuit audio-visual system was used to monitor the simulator environment.
Demographic information
Demographic information was collected through a questionnaire.
The Impact of Event Scale–Revised (IES-R)
The IES-R assesses posttraumatic stress for any specific life event (Weiss & Marmar, 1997). It extracts dimensions that parallel the defining characteristics of the DSM-IV criteria for PTSD (American Psychiatric Association, 1994). The severe range has been found in other studies to have symptoms at a level equivalent to a diagnosis of PTSD (Lavie, Katz, Pillar, & Zinger, 1998). While the IES-R has three subscales and a total scale, only the total scale was used in this analysis. This scale has high internal consistency with a Cronbach’s alpha of .86 and test-retest reliability of .87 (Weiss & Marmar, 1997). In this sample, the Cronbach’s alpha was .90.
State-Trait Anxiety Inventory (STAI)
State anxiety is a commonly used assessment of subjective stress responses and is sensitive to acute stress manipulations (Spielberger, 1983). The State Anxiety (S-Anxiety) scale of the STAI consists of 20 statements (“I am tense”), to which respondents indicate their level of agreement on a 4-point scale regarding how they feel at the given moment (1 = not at all, to 4 = very much so). The internal consistency of the S-Anxiety scale is quite high, with an alpha of .92 (Spielberger, 1983). With this sample, the Cronbach’s alpha was .94 for the baseline administration and .95 for the end-of-scenario administration. In a previous study with paramedics, the S-Anxiety scale was sensitive to anxiety increases following participation in stressful simulated scenarios (LeBlanc et al., 2005). The STAI was completed 10 and 5 min prior to the scenario, immediately at the end of the scenario, and 20 and 30 min after the start of the scenario in order to be accurate.
The Coping Inventory for Stressful Situations (CISS)
The CISS is a 48-item scale with three 16-item subscales that assess task, emotion, and avoidant-oriented coping. When tested on a variety of normative samples including adults, college students, and psychiatric inpatient populations, the CISS had reported alphas of .71 to .86. Its test-retest reliability is adequate (ranging from .51 to .73; Endler & Parker, 1994). In this sample, the Cronbach’s alpha was .71 for the task subscale (M = 64.1, SD = 5.3), .88 for the emotion subscale (M = 40.9, SD = 9.7) and .79 for the avoidance subscale (M = 44.1, SD = 9.2).
Salivary cortisol
Activation of the HPA axis, a physiological response to stress, was measured using salivary cortisol levels. Salivary cortisol levels show a close linear relationship with plasma cortisol levels (Harris et al., 1990). Saliva collection is a simple noninvasive procedure, which is desirable given that we obtained several samples from paramedics. Participants chewed on a roll-shaped collector (Salivettes, Newton, NC) until it was saturated with saliva (~45 sec). The collector was then placed in a collection tube and frozen until analysis. Analyses were conducted using an ELISA technique (Dressendorfer, Kirschbaum, Rohde, Stahl, & Strasburger, 1992). Duplicate analyses of a subset of 10 samples revealed that the intra-assay variability was 7.5%.
Analyses
Pearson correlation coefficients were used to look at the relationship between the anxiety responses to the scenario (measured as the change in STAI scores from baseline to the end of the scenario), cortisol responses to the scenario (measured as the change from baseline to the peak postscenario level) and each of the predictor variables: task-oriented coping styles, emotion-oriented coping styles, avoidance-oriented coping styles, and posttraumatic stress. Although ideally multivariate analyses would be conducted to assess interaction effects, the sample size of this study did not permit such analyses.
Results
Participants completed the IES-R to determine their preexisting levels of posttraumatic stress related to work and life events. The IES-R is divided into four levels of severity. In this sample of 22 participants, 27.3% of the paramedics scored in the no to low trauma symptom range, 9.1% scored in the moderate symptom range, 13.6% scored in the high range, and 50% scored in the severe range.
Subjective anxiety was measured by the State Anxiety Scale of the STAI. At baseline, the paramedics reported mean anxiety levels of 32.8 (SD = 6.7; range = 20-45), which is similar to the average scores of working adults. At the end of the scenarios, the paramedics reported a significantly higher mean anxiety levels of 41.8 (SD = 12.82, range = 24-69; p < .05). Mean scores on this self-report inventory were highest immediately following the scenario and then diminished with time after the scenario. Figure 1 depicts the pattern of scores on the STAI with mean scores reported at each administration of the instrument. Scores at each time period were significantly correlated with each other, suggesting consistency in self-reported anxiety among individual participants. These correlations ranged from r = .40, p < .05 between Baseline 1 and STAI at the end of the scenario to r = .91, p ≤ .001 between 20 min postscenario and 30 min postscenario. Posttraumatic stress was not significantly correlated with anxiety responses to the scenario.
Pattern of STAI scores
At baseline, the paramedics’ cortisol levels were 8.76 nmol/mg (SD = 4.59, range = 2.05-19.18). Following the scenarios, the levels increased 45%, to 12.68 nmol/mg (SD = 12.02, range = 3.48-51.79). This was a significant increase (p < .05). As with STAI scores, there was a strong correlation between baseline levels and postscenario levels (Baseline 1 and postscenario level, r = .51, p < .01; Baseline 2 and postscenario, r = .82, p < .01) demonstrating that a strong predictor of biological stress levels following a stressful encounter is the biological stress level prior to the encounter. Figure 2 depicts the mean cortisol levels at different points in the study design. Posttraumatic stress was not associated with cortisol levels.
Pattern of salivary cortisol response
Results of the correlational analyses revealed that coping styles were associated with both the subjective anxiety and physiological cortisol responses of the paramedic. As demonstrated in Table 1, those paramedics who relied strongly on task-oriented coping styles (r = –.57, p < .01) were less likely to experience subjective anxiety as a result of the high-acuity event. In contrast, those paramedics who relied more heavily on emotion-oriented coping were more likely to report higher anxiety responses to the scenario (r = .52, p < .01) and those who relied more heavily on avoidance-oriented coping styles were more likely to exhibit greater cortisol responses to the scenarios (r = .35, p < .05). Unlike in previous research, coping style was not related to scores on the IES-R (see Table 1).
Correlation Between Anxiety Scores and Predictor Variables
Discussion
This study examined the association between preexisting posttraumatic stress, coping styles, biological markers of acute stress, and subjective anxiety in response to acutely stressful stimuli. In this study, a stressful emergency medical situation was created through the use of a human-patient simulator that was responsive to actions of the participant. Results revealed that level of posttraumatic stress was not associated with biological or subjective indicators of stress and anxiety. However, both subjective anxiety and cortisol responses to the clinical scenarios were associated with the coping styles of individuals.
Response of participants to the simulated emergency was evaluated by collecting salivary samples for cortisol analysis and repeated administration of a subjective measure of anxiety (STAI). Mean scores on the STAI peaked immediately following exposure to the scenario and then declined in the recovery period. Consistent with previous research on cortisol response to stress, cortisol scores peaked 20 to 30 min following the exposure (Dickerson & Kemeny, 2004; Kemeny, 2003). As such, these findings provide support for the use of simulators as a means of eliciting both biological and psychological stress response and as a proxy for high-stress workplace events.
The IES-R was administered to determine levels of posttraumatic stress resulting from previous workplace and life events. Contrary to previous research, the level of posttraumatic stress was not associated with the paramedics’ responses to the acute event. One possible explanation may lay in the fact that the large majority of the paramedics in this study, more than 60%, reported high to severe levels of trauma symptoms. In comparison, cross-sectional design studies have demonstrated that at any given time, approximately 20% to 30% of paramedics that are currently on the job are experiencing significant trauma symptoms at a level consistent with a diagnosis of PTSD (Alexander & Klein, 2001; Regehr et al., 2002). With the bulk of our sample skewed toward the high-to-severe end of the range of posttraumatic stress, it is possible that the relationship between posttraumatic stress and acute stress responses may not be fully captured in this study. However, these findings replicate our work with a larger sample of police recruits which also did not find an association between posttraumatic stress and biological stress response (Regehr, LeBlanc, Jelley, Barath, & Daciuk, 2007). Unlike the previous study, level of posttraumatic stress also did not predict subjective anxiety as measured by the STAI.
The paramedics’ coping styles were strongly associated with subjective anxiety and physiological stress responses to the scenario. Whereas task oriented coping styles appear to serve a protective role and are associated with decreased anxiety in response to a high-acuity event, emotion-oriented was associated with greater anxiety response. These results support the idea that task-oriented coping is a healthy and effective method of dealing with stressors and that emotion may be an ineffective coping mechanism in stressful work situations (Beaton, Murphy, Johnson, Pike, & Corneil, 1999; Bramsen et al., 2000; Fortes-Ferreira et al., 2006).
Interestingly, paramedics who scored high in avoidant-oriented coping styles demonstrated higher cortisol responses in the absence of increased anxiety, as measured by the STAI. This suggests that they were experiencing a physiological stress response despite their lack of recognition, or even perhaps the suppression, of an emotional reaction. In research with emergency workers, avoidant-oriented coping styles have been associated with a higher likelihood of trauma levels consistent with a diagnosis of PTSD, specifically symptoms of arousal and intrusion (LeBlanc, Regehr, Jelley, & Barath, 2008). It is possible that avoidant-oriented coping styles may have some functional benefit in the short term, by preventing individuals from focusing on the causes of stress or the distressing emotions prior to, during, or immediately following a stressful event. Previous interview-based studies with paramedics revealed that the ability to engage in “detached concern” is considered helpful by the paramedics in stressful or traumatic events (McCammon, Durham, Allison, & Williamson, 1988; Regehr et al., 2002). Thus, coping mechanisms that allow for the avoidance of emotions may be perceived as helpful during a high-acuity event. They allow the emergency worker to control strong emotional reactions and to do their work. In the longer term, however, strategies aimed at suppressing and avoiding the strong emotions of trauma are thought to contribute to ongoing physical and psychological harm resulting from traumatic experiences (Folkman & Moskowitz, 2004; McCammon et al., 1988; Thoits, 1995; Wastell, 2002). Furthermore, elevated cortisol responses have been associated with impairments in performance (LeBlanc, 2009), suggesting that while these workers may subjectively feel as if they are controlling their emotions and doing their work, their performance may in reality be impaired. Further research is required to explore the link between avoidant coping styles and performance in high-acuity situations.
Limitations
An obvious limitation of this study is the small sample size of 22 participants. Although a larger sample size would have been ideal, the study involved a highly complex and costly procedure involving simulator time, standardized patients, a considerable time commitment from participants, and analysis of biological samples. Consequently, we were unable to collect data from additional participants, and further research with larger sample sizes is warranted. This study attempted to simulate an acutely stressful emergency medical encounter. Although participants did experience both psychological and biological response to the situation, we cannot be certain that their stress response would be replicated in a real-life workplace encounter. In addition, physiological and psychological distress were only measured within a short time frame and thus long-term follow-up will be useful.
Conclusion
This study used an experimental design to better understand the interaction between level of posttraumatic stress, coping styles, and both subjective and biological response to an acutely stressful situation. In this study, preexisting posttraumatic stress was not associated with subjective anxiety or biological indicators of stress. This suggests that high levels of posttraumatic stress among paramedics do not place them at increased risk of distress during high-stress clinical situations. Rather, stress responses to potentially stressful acute situations were associated with the coping styles of individuals. Individuals with task-oriented coping styles exhibited decreased anxiety responses to a potentially stressful scenario. In contrast, emotional and avoidant coping styles were associated with greater anxiety and cortisol responses. Coping strategies are modifiable, and thus interventions aimed at training emergency workers to use task-oriented coping styles may be effective in reducing stress responses to high-acuity events. Given the accumulating evidence that stress responses are associated with decreased clinical performance, such interventions could result in increased quality of patient care in the community.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was generously supported by a grant for the Foundation for Air Medical Research and Education, now called the MedEvac Foundation.