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Burnout Within Private and Public Emergency Medical Service Systems
Research Topic
Our chosen topic of research is to compare stress and burnout among providers within
private and public emergency medical service departments. Our goal is to educate current and
future providers about burnout, with the hopes of improving mental health, no matter the agency
one works for. There has been an increasing amount of peer support and psychological therapies
developed for dealing with work-place trauma, but all too often, providers see burnout as a result
of trauma, which is a common misconception of this condition. Burnout can be caused by a
variety of factors such as over working, decreased quality of life, and overall stress. This study
will be aimed to provide psychological awareness and assistance for any provider in need,
independent of workplace factors.
Problem Statement
To compare stress and burnout among providers within private versus public emergency medical
service departments. This research will address possible factors that contribute to mental,
emotional, and physical exhaustion to better educate those working in emergency medicine of
healthy and unhealthy coping strategies.
Significance
The purpose of this study is to identify key risk factors for burnout in prehospital medical care
providers, focusing mainly on rates of burnout in public emergency medical services systems
versus private EMS systems. Identifying differences in burnout rates among these systems will
help providers by highlighting sources of the kinds of stress that cause burnout. Identifying
which type of system has the most workplace burnout will give a general direction for
improvement. It will also serve as a framework for future research studies in this area. Using this
research, a more in-depth study may be undertaken to identify specific factors that make burnout
more likely.
Annotated Bibliography
Crowe, R. P., Bower, J. K., Cash, R. E., Panchal, A. R., Rodriguez, S. A., & Olivo-Marston, S.
E. (2017). Association of burnout with workforce-reducing factors among EMS
professionals. Prehospital Emergency Care, 1-8. doi:10.1080/10903127.2017.1356411
This study investigates the prevalence of burnout associated with Emergency Medical
Services (EMS) professionals, and attempts to quantify the relationship between burnout
and other factors that negatively affect an EMS workforce, such as sickness and attrition.
The study uses a simple random sample (SRS) of roughly twenty thousand emergency
medical technicians (EMT) and paramedics selected from the National EMS Certification
database. The individuals selected for the sample received a questionnaire to assess their
rating on the Copenhagen Burnout Inventory (CBI) in their personal, work-related, and
patient-related performance. The study showed that burnout was more prevalent in
paramedics than EMTs. The study also indicated that variables associated with higher
burnout rates were years of experience in the job, and weekly call volume. Burnout was
associated with a two-fold increase of sickness related absence. The authors urge a closer
look at the variables influencing burnout, and further research to investigate the
associations made in this study.
Gregov, L., Kovacevic, A., & Sliškovic, A. (2011). Stress among Croatian physicians:
comparison between physicians working in emergency medical service and health centers
– pilot study. Croatian Medical Journal, 52(1), 8-15. doi:10.3325/cmj.2011.52.8
This study aimed to determine the sources of stress and its frequency in Croatian
physicians working in emergency medicine and health centers. The researchers took a
sample of convenience of 79 EMS physicians and 81 health center physicians and issued
them a questionnaire relating to demographics, stress scales, their intent to leave the job,
and psychosomatic symptoms. EMS physicians were found to report significantly more
unfavorable working conditions, family role/interactions, and workplace relationships.
Halpern, J., Maunder, R. G., Schwartz, B., & Gurevich, M. (2014). Downtime after critical
incidents in emergency medical technicians/paramedics. BioMed Research International,
2014, 1-7. doi:10.1155/2014/483140
The authors in this study examined the downtime after a critical incident for emergency
medical services (EMS) healthcare providers. The main purpose of this study is the show
that it is highly important for EMTs and paramedics to have downtime following a
critical incident. According to the authors of this study, doing this can prevent
posttraumatic stress disorder (PTSD) and burnout symptoms. Additionally, in this study
the authors mentioned there is evidence that downtime post critical incident is associated
with fewer symptoms for long-term effects of depression and stress-related emotional
symptoms. The authors acknowledge that various critical incident types may require
different interventions.
Halpern, J., Maunder, R. G., Schwartz, B., & Gurevich, M. (2012). The critical incident
inventory: characteristics of incidents which affect emergency medical technicians and
paramedics. BMC Emergency Medicine, 12(1). doi:10.1186/1471-227x-12-10
The main objective of this research is to show that emergency medical technicians
(EMTs) and paramedics are subject to critical incidents. The author in this study aimed to
show that the presence of previous critical incidents among EMTs and paramedics may
interfere with patient care. This study also showed that posttraumatic stress disorder
(PTSD) is found in at least 20% of EMTs/ paramedics and that paramedics are more
susceptible to experience burnout than other healthcare providers.
Hassan, T. B. (2014). Sustainable working practices and minimizing burnout in emergency
medicine. British Journal of Hospital Medicine, 75(11), 617-619.
doi:10.12968/hmed.2014.75.11.617
This study shows that working as an emergency physician for an extended number of
years can have a toll on the patient care rendered. It specifically states that even though
physicians may enjoy their jobs, they still experience immense emotional distress from
the constant demands of their workplace. Another point made is that from the first time
this area was observed in 1993, the number of physicians that felt burnout was a
significant problem has remained constant up until a study done in 2004 (31%-33.4%),
showing that not much improvement had been made concerning mental health of
emergency medical providers within this timespan.
Ilic, I., Arandjelovic, M., Jovanovic, J., & Nešic, M. (2017). Relationships of work-related
psychosocial risks,stress, individual factors and burnout – Questionnaire survey among
emergency physicians and nurses. Medycyna Pracy. doi:10.13075/mp.5893.00516
Due to the high level of workplace environment and personal responsibility, physicians,
nurses, and EMS providers suffer from burnout. Their situation and mental status is
shown to be ignored from their administrative staff, which prevents healing and the
implementation of progressive treatment. Those with good coping mechanisms, degree
of freedom at work, and overall good mental health are shown to have a lower prevalence
of burnout within the workplace environment.
Popa, F., Raed, A., Purcarea, V. L., Lala, A., & Bobirnac, G. (2010). Occupational burnout
levels in emergency medicine–a nationwide study and analysis. Journal of Medicine and
Life, 3(3), 207-215.
This particular study looks at Romanian emergency medical workers and determines
which occupations are at the greatest risk for high levels of emotional exhaustion and
depersonalization. The research observes paramedics, ambulance drivers, nurses,
physicians, and various physician and nursing departments within the hospital. The end
findings shows that emergency department doctors and resuscitation service doctors
experience the highest levels of emotional exhaustion and depersonalization.
Sand, M., Hessam, S., Sand, D., Bechara, F. G., Vorstius, C., Bromba, M., . . . Shiue, I. (2016).
Stress-coping styles of 459 emergency care physicians in Germany. Der Anaesthesist,
65(11), 841-846. doi:10.1007/s00101-016-0228-6
The goal of this study is to observe coping strategies within the emergency physician
population to raise awareness to the lack of (or presence of) these methods. The study
was conducted by utilizing the German Stress Coping Strategies Inventory which
measures coping mechanisms through levels of social support, avoidance, escape,
rumination, resignation, minimization, and denial of guilt. The findings showed women
to have a higher prevalence than men of all categories aside from minimization and
denial of guilt.
Schooley, B., Hikmet, N., Tarcan, M., & Yorgancioglu, G. (2016). Comparing burnout across
emergency physicians, nurses, technicians, and health information technicians working
for the same organization. Medicine, 95(10). doi:10.1097/md.0000000000002856
The purpose of this study is to identify different factors causing burnout in emergency
medicine personnel, rather than the prevalence among them. The research was conducted
by measuring the effects of emotional exhaustion, depersonalization, and overall sense of
personal accomplishment. They found that while various professions in emergency
medicine were found to have equal level of depersonalization, sense of self
accomplishment and emotional exhaustion differed drastically. It was also found that
socioeconomic factors played a larger role in burnout effects than interpersonal
relationship status. More research is needed to determine direct factors on these criteria.
Sterud, T., Hem, E., Lau, B., & Ekeberg, O. (2011). A comparison of general and ambulance
specific stressors: predictors of job satisfaction and health problems in a nationwide oneyear follow-up study of Norwegian ambulance personnel. Journal Of Occupational
Medicine And Toxicology (London, England), 6(1), 10. doi:10.1186/1745-6673-6-10
The objective of this study is to determine the significance of job-related stressors,
ambulance stressors, and individual characteristics as it relates to possible symptoms of
burnout (overall illness, exhaustion, and dissatisfaction). The study found that different
aspects correlated with the various stressors. Physical demands, neuroticism, lack of
leader support, and time pressure were all variables that were shown to affect various
types of stress.
Tunaligil, V., Dokucu, A. I., & Erdogan, M. S. (2016). Determinants of general health, workrelated strain, and burnout in public versus private emergency medical technicians in
Istanbul. Workplace Health & Safety, 64(7), 301-312. doi:10.1177/2165079916632243
This article was written about a study done in Turkey to measure the total amount of
burnout in public versus private ambulance companies. The three key measurements
taken to determine if an employee was experiencing distress was emotional exhaustion,
depersonalization, and diminished personal accomplishment. This study measured the
prevalence of burnout among EMT-Bs only and determined that it wasn’t the numbers,
but the reasons of burnout occuring, that varies among the two types of organizations.
Hypothesis and Conceptual Model
Hypothesis
Emergency medical service (EMS) providers working for private ambulance companies
will have higher prevalence of burnout as compared to EMS providers working for public
systems.
Conceptual Model
Provider Burnout. Burnout is a very common thing among EMS providers. Emergency
personnel suffer from very high levels of burnout and it has been an issue, due to the extreme
stress of the job. EMS providers start their work and they have no idea what to expect. Whether
it be a fatal car accident or a cardiac arrest, providers are expected to be ready for anything.
Listed are various contributing factors that EMS providers face which may lead to an increase in
burnout.
Coping Mechanisms. Coping mechanisms play a large part in determining the ability to
recover after a traumatic event. Though healthy coping skills may be difficult to obtain, it has
been shown that positive methods correlate with increased resilience to stressful incidents
(Hamill, 2003). Therefore, it is predicted that negative coping mechanisms will have increase
provider burnout, while positive mechanisms will decrease burnout. In a study performed during
1999, correctional officers were examined to determine the relationship between various coping
skills and handling work stressors. The study showed that different people deal with stress in
various ways, but those that had a “go-to” relief from stress seemed to respond better to
excessive overall stimulation in the workplace (Triplett & Mullings, 1999). Therefore, different
mechanisms consisting of the utilization of family/ friends, peer support, exercise, and the lack
of drug abuse are predicted to decrease burnout, while those that have negative coping skills are
projected to have a higher burnout prevalence.
Personality Type. Personality type can have a significant effect on one’s ability to cope
with stress. As Friedman & Rosenman (1976) posited, those who exhibit Type A Behavioral
Patterns are at higher risk of heart disease and other chronic, stress related illnesses. Type A
Behavioral Patterns can be described as a tendency to be competitive and self-critical. Friedman
& Rosenman (1976) also noted that Type A personalities also experience a constant sense of
urgency, and often exhibit hostility towards others when under stress. Type B Behavioral
Patterns are hallmarked by a tendency to take things one step at a time, and a greater degree of
tolerance and acceptance of delays. Type C Behavioral Patterns are typified by a lack of ability
to communicate effectively and cope with stressful situations. Stress, from a physiological
standpoint, has profound effects on the body. Stress hormones like cortisol and norepinephrine
contribute to various chronic illnesses like heart disease, certain cancers, and diabetes. From a
psychological perspective, stress contributes to emotional weathering and can have significant
effects on one’s ability to cope with future stress events. These factors combined contribute to
the allopathic load one experiences throughout life (McEwen, B., & Seeman, T., 2009).
Personality type’s influence on EMS personnel and burnout cannot be understated.
Workplace Culture. Individuals in the workforce tend to work better when placed with
people who possess good character. EMS providers who work under officers that have little
experience managing an organization may find it stressful to be involved in that type of
environment. Having supervisors and managers that do not respect the provider’s personal time
(I.E days off for family issues) can also contribute to poor workplace environment, leading to
higher rates of burnout.
Work/Life Balance. Within the realm of life, it is important to balance all things that you
do, whether positive or negative. Though people may believe the contrary, it is extremely
important to have the ability of separating work factors from personal life. One must obtain the
ability to focus on work when they are there, and focus on personal goals and achievements
when they are not. In WW1, a study was performed on soldiers that tested the difference between
complete removal of stimuli, from partial removal. This study concluded that “return to duty”
rates were much higher when soldiers were completely removed from the war-zone, than those
that were partially removed, or not removed at all (J. Mitchell, 2017). Based on this knowledge,
it is predicted that the routine removal of workplace stressors will increase mental capacity, and
in turn, decrease burnout prevalence.
Urban/Rural System. The impact of location on an EMS systems burnout rate is rooted in call
volume and type. Rural areas will have fewer calls per shift, as populations are less dense. Urban
areas will have a higher call volume, and will likely involve trauma related calls, or calls
associated with violence. These elements can have varying effects on the providers serving in
these areas.
Time in Service. The longer a provider spends in service, the more at risk they are of
experiencing burnout. Veteran EMS providers will have experienced more non-emergent calls
that aren’t resourceful to the system as a whole versus new EMS providers who enjoy the thrill
of any call no matter how critical.
Average Calls per Shift. The number of calls plays an important role in developing
burnout to EMS provider. Depending on the region the EMS provider serves at, they may receive
a high call number per shift, which can increase the stress and decrease quality of patient care. In
some regions that contain a higher population, EMTs and Paramedics may receive an incredible
number of calls per shift, decreasing rest time, which can lead to a unique stress and burnout.
Typical Patient Priority. In various studies, it has been shown that witnessing critical
incidents within emergency medicine can have a long-term effect on patient care. In a study
performed on paramedics and EMTs, results showed a 20% prevalence of PTSD within active
providers (Halpern, et al., 2012). These results indicate a possible correlation between the patient
care provided and the exposure to psychologically unresolved calls. The more a person
experiences these calls, the less time the brain has to process the trauma. Therefore, an increase
of high priority patients (priority 1 and 2) may coincide with a higher burnout rate due to a lack
of appropriate emotional and mental recovery time.
Methods
In order to measure levels of stress and burnout among providers, we will use two
different surveys; The Maslach Burnout Inventory (MBI) and a supplemental self-created survey.
While the MBI will aim to measure levels of burnout itself using a quantitative scale, the selfcreated survey will aim to assess predicted causes of burnout within Emergency Medical Service
(EMS) providers using a qualitative scale of measurement. Then, we will merge both qualitative
and quantitative survey results into a excel spreadsheet to identify trends within the collected
data. Both surveys are explained in further detail within the content of this paper.
The recruitment process for this research will include random visits to various
departments throughout the county. Each station/base will be targeted for one week. A lock box
will be placed within this station, and a total of 50 surveys will be printed and left near the lock
box. By using this method, the goal is to decrease employee pressure for answering the survey
quickly and to give them enough time to take the survey home and answer it honestly, without
the influence of others. The employees will be encouraged to fill the survey out by raising
awareness about mental health within the department and by promoting the possibility for
improvement within the company.
Using the survey technique may create bias among answers, such as those that have a
neutral opinion may abstain from filling a survey out and those who work harder within the
company may not foresee time to put aside for a survey. We will aim to promote the benefit of
completing the survey, as well as initiate appropriate time windows for provider involvement,
with the hopes of increasing accuracy responses and decreasing lack of participation, which will
in turn, decrease the amount of foreseen bias.
The hypothesis of the study is aimed at differentiating mental health burnout within
public companies versus private companies. While the chosen definition of a public organization
is the presence of governmental dictation over protocol decisions and monetary declarations
within the company, private organizations will be based on a separate source of income and a
non-governmental connection to procedures within the company. Therefore, five private
companies and five public companies will be chosen to be a part of this study, varying from
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