EL PROYECTO “EDUCACIÓN POR LA IGUALDAD”

This chapter presents an overview of the literature most pertinent to the three main concentration areas of this study. The Emergency Medical Care (EMC) profession, both internationally and in South Africa, will be discussed, focusing on its status as a critical occupation and on the characteristics and challenges of EMC practitioners, paramedics.

Vicarious trauma, or, the indirect trauma paramedics experience as a consequence of being exposed to the trauma of their patients will be described, as well as its effects on them and the various ways they cope with it. Finally, the concept of adversarial growth, or growth through adversity, describes the positive changes that may result after experiencing stressful or traumatic events.

Emergency Medical Care

Emergency Medical Care (EMC), also known as Emergency Medical Services (EMS), refers to the pre-hospital treatment of the critically ill or injured in need of urgent medical attention. Paramedics provide advanced life support procedures to their patients, stabilizing them in the field before transporting them to medical facilities (www.dut.ac.za; www.uj.ac.za).

The psychology of work will briefly be focused on before the specifics of EMC as a critical occupation is discussed. Although the present study is not situated within the career psychology field, it is important to bear in mind that the experiences of trauma and growth that will be explored are not just caused by, but are in a sense inherent to the nature of the EMC occupation, and thus to the work lives of EMC practitioners – paramedics. It is therefore appropriate to offer some comments on the psychology of work in order to provide a background to the discussion of EMC as a critical occupation and of those who work in the field. With regard to the latter, the focus will fall on EMC training, with an emphasis on the importance of the

psychological preparedness of newly qualified paramedics, and the support services available to them in the field.

The Psychology of Work. Work has a significant impact on people’s lives, as has been established by numerous authors (e.g., Judge & Watanabe, 1993). This impact is not restricted to the material gains and deprivations that may be associated with a particular profession; it also includes the role of work in establishing a person’s social status, personal identity, meaning in life and psychological well-being. Choosing a career is a challenging task, and before making the final choice individuals have to take many dimensions into account that encompass their lives. The following factors are particularly pertinent: “aptitudes, interests, resources, limitation, requirements and opportunities” (Antoniou & Cooper, 2005, p. 580).

Examining the reasons why people are motivated to work in a particular occupation, even if unrewarding, could contribute to an understanding of the importance an occupation plays in individuals’ lives, what makes work meaningful for them, and what leads to positive outcomes in their lives. Work provides an anchor which affords continuity, stability, and structure (Schabracq, in Schabracq, Winnubst, & Cooper, 2003).

Work, and the meaning it holds for an individual, can be described in three ways:

merely a job (a means of ensuring a livelihood or salary); a career (the individual’s record of success, accomplishments and need for recognition); or a calling (a conviction to do something specific which comes about as a result of combining inner nature and external circumstances) (Baumeister, 1991). Work plays a particularly significant role in the identity of individuals who regard their work as a calling, as it is the engagement with their chosen occupation that brings fulfilment (Roberts & Dutton, 2009). Naudé and Rothmann (2006) define work engagement as being “a positive, fulfilling, work-related state of mind that is characterised by vigour, dedication and absorption” (p. 65), and may be an indicator of how ‘well’ employees are at work.

Viktor Frankl suggested that people create meaning through their occupation (Coward, 1996). Researchers accept that individuals’ life work contribute to them experiencing meaning in life, and that those whose work have a meaningful influence on others will experience it as very gratifying (Antoniou & Cooper, 2005; Wong & Fry, 1998).

Work can therefore become a life-long focus in an individual’s search for meaning.

Pines (2005) comments that this is the reason why people often enter their occupation “with very high hopes, goals and expectations, idealistic and motivated, and why many relate to their work as a calling” (as cited in Antoniou & Cooper, 2005, p. 579). According to Hagmaier and Abele (2014), a job can be described as being a calling if it includes the following three components:

… a perfect fit between their skills and interests and the requirements of the job … show value-driven behavior (e.g., altruism and morality) while performing their work and hope to contribute to the good of humanity … and the sense of an affirming transcendent guiding force … some people with a calling also experience a transcendent guiding force (e.g., God or an inner voice), which makes them feel secure about their career path and certain that they are doing the right thing … (p. 2)

Paramedics often view their work as a true vocation. As such it may therefore have a profound impact on how they define themselves and understand life.

Emergency Medical Care: A Critical Occupation. Emergency medical care is approached in this study as a ‘critical occupation’. Members of a critical profession play a crucial role in safeguarding the well-being of others. Their work often exposes them to events which may have a critical impact on their own well-being (Paton & Violanti, 1996).

The EMC profession epitomizes the definition of a critical occupation. Generally speaking, individuals working in the caring professions are already at higher risk than most other professions for experiencing work stress (Sabin-Farrell & Turpin, 2003). This also

applies to paramedics and is arguably even more acute in their case. Paramedics are characterized as a high-risk group by the nature and reality of the work they do (Paton &

Violanti, 1996).

Figley (1995) describes paramedics as being “front-line first responders” who are almost assured of being exposed to work trauma in every shift (p. 51). Paramedic teams are first responders in the sense that they, “in the early stages of an accident or disaster, are responsible for the protection and preservation of life” (Prati & Pietrantoni, 2010, p. 403).

Being exposed to stressors of a traumatic nature is therefore “an integral part of the job” (Ward et al., 2006, p. 226). Van der Ploeg and Kleber (2003) add that paramedics are subjected to

“more chronic stressors in their work than workers in other health service settings” (p. 141).

Paramedics thus fulfil a vital role in every community, yet may not always realize the

“significance of their services, both in a larger (systems) context and for the affected family”

(Martinez, Ryan, DeLeon, Routh, & Templar, 1995, p. 541).

Sterud, Hem, Lau, and Ekeberg (2011) describe paramedics as follows:

Ambulance workers frequently have to take rapid action and provide medical care under life-and-death circumstances in unfamiliar and inconvenient conditions, while being scrutinized by bystanders and relatives. Ambulance personnel must also attend to non-emergency work, such as transporting and providing appropriate care to chronically and terminally ill patients, which imposes different emotional demands and which might be experienced as more emotionally exhausting than more

sensational events. (p. 1)

In addition to being in a critical occupation, the traumatic stressors paramedics are exposed to can also be described as ‘critical incidents’. These incidents typically involve exposure to death or life threatening injury, and, because of the intense emotional reactions that may be evoked, paramedics’ coping mechanisms may be stretched to the limit (Figley, 1995).

Individual Differences. Research has found that there is an interaction between individuals’ characteristics and the particular environmental stressors to which they are exposed. Based on this knowledge it is thus possible to determine the amount of strain experienced by an individual, as well as the effects of stress on the individual’s behaviour and health (Antoniou & Cooper, 2005).

Individuals differ in the extent to which they respond to and how they deal with stressful situations (Eschleman & Bowling, 2010). According to Park (1998), individual characteristics which impact on how people react to stress, both negatively and positively, include personality, resources, and beliefs: “These characteristics, along with situational factors, may also determine the extent to which people thrive or experience growth through responding to and coping with stressful and traumatic experiences” (p. 268).

According to Aldwin (2007), exposure to trauma is “a function of both individual differences in susceptibility to traumatisation as well as situation characteristics” (p. 216).

Individuals differ as far as their appraisal of the intensity of stressors are concerned, and researchers need to take into account the importance of the specifics of individual responses (Beaton et al., 1998). This applies to paramedics as well. Even though there are many descriptions in literature as regards the various, mostly harmful, cumulative effects of stress and trauma on paramedics as an occupational group, it has to be concluded that not all paramedics will develop negative consequences “following exposure to duty related traumatic events, and that it is therefore of interest to investigate the variables mediating individual stress-strain relationships” (Lowery & Stokes, 2005, p. 171).

Members of critical occupations are not homogeneous, and, as noted above, a number of different influences could affect their susceptibility to threats in their environments, including, functional, demographic, status, and geographical factors (Paton & Smith, 1996).

Members’ unique personal reactions to these factors will therefore bring about individual differences:

… differences should not be assumed, a priori, only to relate to differences in susceptibility to negative reactions. They could, by virtue of their potential for influencing the development of special coping and adaptational strategies that affect sensitivity to emotional and psychological demand, drive differences in the incidence of positive resolution. (Paton & Violanti, 1996, p. 24)

In other words, the personally lived reality of paramedics result in them being a heterogeneous group. Research should acknowledge the different effects that traumatic events may have on individuals: “those individual and situation factors which precipitate the negative psychological responses, those factors which predispose the responses, and those which amplify or ameliorate them” (Paton & Smith, in Paton & Violanti, 1996, p. 26).

It is important for this study to note that individuals may react differently to the effects of trauma. Occupational groups may therefore not necessarily exhibit similar post trauma effects. In the words of a paramedic: “the stresses that paramedics feel are very individualized”

(Regehr et al., 2002b, p. 510).

Paramedics: Emergency Medical Care Practitioners. Paramedics are the first responders who arrive at accident scenes, and are often confronted with unimaginable scenes of disaster. They have to face the physical injuries, agonies, and emotional reactions of victims, yet act professionally while hiding their own feelings of fear, guilt, sadness and distress.

Paramedics “find their victims in their homes, on the street, under wrecked cars, in demolished buildings. The deaths they witness … are typically sudden, messy, noisy, agonized, and undignified” (Miller, 1995, p. 594).

Clohessy and Ehlers (1999) describe paramedics as “skilled individuals who work under conditions of extreme stress, witnessing many distressing scenes, and whose

performance … may literally mean the difference between life and death” (p. 262). A study on paramedics revealed that “100% had been exposed to a critical event in the line of duty; that is, physical risk to themselves, mass casualties, the death of a person in their care, the death of a child, or the death of a colleague” (Regehr, Goldberg, Glancy, & Knott, 2002a, p. 956). As such paramedics not only experience the pain and misfortune of their patients, but their own well-being is often at risk:

…more than 80% of those in a large urban area had experienced each of the following events: the death of a patient while in their care, the death of a child, events involving multiple casualties, and events involving violence perpetrated by one individual against another … 70% had been assaulted on the job and 56% reported experiencing events on the job that they believed could potentially have resulted in their own death.

(Regehr, 2005, p. 97).

A certain profile of EMC practitioners has emerged in literature. Mitchell (1983) developed the concept of the ‘Rescue Personality’ with specific reference to paramedics, and characterizes those who work in emergency medical care as being “inner-directed, action oriented, obsessed with high standards of performance, traditional, socially conservative, easily bored, and highly dedicated” (Wagner, Martin, & McFee, 2009, p. 5).

The traditional image of first responders is often presented as follows: “[an] extremely stoic façade, an unemotional response, and as a result, a presence that is always relied on by the public to bring order out of chaos and security out of fear” (Carll, 2007, pp. 274, 275).

Although the expectation is that paramedics will deal with each crisis in a calm and efficient manner, they are by no means immune to the vicarious trauma they are exposed to. In reality they have to employ all their resources, both physical and psychological, to combat the effects of trauma, and may supress their feelings for the sake of co-workers, family, and friends in order not to show any vulnerability.

The perception exists that paramedics should be resistant to the effects of trauma, and their “professional identities often rely of this self-image of strength and resilience” (Bryant &

Harvey, 2000, p. 157). Figley (1995) notes that Beaton and Murphy are credited as designating this phenomenon the ‘John Wayne syndrome’, one which constitutes the “macho, male cultural characteristic” (p. 75) that many paramedics exhibit.

Various studies have identified a number of characteristics that contribute to an understanding of the hardy nature of paramedics. Pajonk et al. (2011) note that thepersonality characteristics of paramedics usually exhibit “particularly high levels of tolerance for hazards and frightening stimuli as well as showing a willingness to compete (eg, against time or death)”

(pp. 141-142). The authors identify the following characteristics in their study: resilience, stability, readiness to take risks, controlled, altruistic, responsible, and secure. Klee and Renner’s (2013) study finds that EMS workers scored high on the trait of conscientiousness, which aligns strongly with the helping and saving aspect of their profession, while Regehr (2005) finds the following characteristics as being definitive of EMC personnel: “taking control, springing into action, remaining detached, making quick and decisive decisions, and questioning everything” (p. 98). In order to cope with the realities described above, paramedics require specific traits and skills. Education and training will only be able to build on and enhance the set of inherent personal characteristics and skills required for the job in order to be adequately equipped for this high-risk profession (Paton & Violanti, 1996). However, no training can completely prepare paramedics for the realities they will encounter throughout their working career. Cognisance should be taken of the fact that personality characteristics typically only explain “a portion of the variance of behaviour” (Pajonk et al., 2011, p. 145) and that additional factors have to be taken into account.

Emergency Medical Care Training.Martinez et al. (1995) provide a succinct yet detailed description of the different aspects the EMS system entails, and describe it as being a carefully orchestrated process to ensure that injured victims have the best chance for recovery and that health care resources are used efficiently. The complex system of care starts with prevention and continues through rehabilitation. It is critical that the process is well coordinated. The system consists of the following components: (a) comprehensive, enabling systems legislation; (b) communication and transportation systems; (c) inclusive, fully integrated trauma systems; (d) human resources and training; (e) quality improvement mechanisms; (f) data collection and research; (g) public education; (h) treatment facilities; and (i) medical direction.

Paramedics represent the “human resources” of the system, and it is imperative that they not only be provided with up to date medical knowledge and skills, but that they are also prepared as thoroughly as possible as far as the psychological and emotional demands are concerned. Preparation to work in the emergency medical service thus requires a comprehensive approach:

Comprehensive training to work with traumatized populations requires didactic instruction in the myriad forms of traumatic events and potential emotional,

behavioural, cognitive, and somatic responses to psychological trauma. It also must include extensive professional skills training and supervised practical experience in working with trauma-exposed groups for the involved service-provider. (Courtois &

Gold, 2009, p. 16)

Emergency Medical Care Curricula. The emergency medical care occupation

requires that personnel are comprehensively equipped, both academically and practically, for the uncommon high-risk demands of rescue work. It is therefore important that training courses and study programmes provide them with the latest medical knowledge and skills.

When considering emergency medical care curricula, it is evident that similar approaches regarding the structure and content of EMC programmes are followed internationally. The United States of America and the European Union may be taken as examples. The ‘EMT-Paramedic National Standard Curriculum’ as published by the United States Department of Transportation National Highway Traffic Administration (Stoy, 2009) and the ‘European Curriculum for Emergency Medicine’ as published by the European Society for Emergency Medicine (Petrino, 2009) show notable similarities in their core curricula content.

The American curriculum framework includes the following main components:

didactic instruction, skills laboratory, clinical education, and field internships (Stoy, 2009). The European framework sections are: patient care, medical knowledge and clinical skills;

communication, collaboration and interpersonal skills, professionalism and other ethical and legal issues, organisational planning and service management skills, and education and research (Petrino, 2009). The European curriculum document provides a comprehensive list of system-based core knowledge, common presenting symptoms, specific aspects of emergency medicine, and core clinical procedures and skills that need to be included in all EMC programmes. In contrast, the American document does not list specific programme content.

The assumption is that programme and module content will be provided by those institutions that offer EMC qualifications.

Eastern Kentucky University’s list of course descriptions for their EMC degree can be taken as an example of the typical module components found in such a programme. The modules include: first responder EC, basic health care support, survey of medical terminology, introduction to EMC, assessment of human systems, prehospital advanced life support, prehospital management for obstetrics and gynaecology emergencies, crash victim auto extrication, introduction to pharmacology, electrocardiography, advanced cardiology,

paediatric advanced life support, advanced trauma and medical emergency life support, disaster medical operations, research, and clinical and field experience and internships (emc.eku.edu/course-descriptions).

Verdile, Krohmer, Swor, and Spaite (1996) distinguish between didactic and experiential on-scene elements in the EMS curriculum. According to them the didactic elements include the following: overview of EMS, EMS structure and components, medical direction, communication, patient care (trauma, triage, cardiac arrest, airway management, specific clinical conditions), rural EMS, emergency air EMS, legal aspects, disaster management, and administrative aspects.

McLaughlin, Doezema, and Sklar (2002) offer an alternative approach, and propose that human simulation forms the core of emergency medicine training. They describe it as follows:

Human simulation refers to a variety of technologies that allow residents to work through realistic patient problems so as to allow them to make mistakes, learn, and be evaluated without exposing a real patient to risk. This curriculum incorporates 15 simulated patient encounters with gradually increasing difficulty, complexity, and realism... The core competencies are incorporated into each case focusing on the areas of patient care, interpersonal skills and communication, professionalism, and practice based learning and improvement. (p. 1310)

Such an approach ensures the immediate integration of theory and practice, and would be invaluable in preparing paramedics for the reality of their on-scene work. It may be the preferred curricular format of the future.

Psychological Preparedness. The question may be asked whether paramedics’

training and experience prepare them adequately for the uncharacteristic demands their work will bring (Paton & Violanti, 1996, p. 173). While paramedics may possess the technical skills required to meet the needs presented by patients, their training may not provide them with the psychological and self-maintenance skills required to readily comprehend their disaster experience, or to understand and deal effectively with the aftereffects of that trauma on

training and experience prepare them adequately for the uncharacteristic demands their work will bring (Paton & Violanti, 1996, p. 173). While paramedics may possess the technical skills required to meet the needs presented by patients, their training may not provide them with the psychological and self-maintenance skills required to readily comprehend their disaster experience, or to understand and deal effectively with the aftereffects of that trauma on