Research PaperMindfulness for healthcare providers fosters professional quality of life and mindful attention among emergency medical technicians
Introduction
Healthcare workers frequently witness psychologically intense and physically exhausting stimuli during their work. Emergency medical service (EMS) providers are vulnerable to both acute and chronic psychological distress as they are often called to witness death, loss, and suffering. The adverse sequelae of these incidents may result in secondary trauma if untreated. When exposed to this everyday suffering chronically, many healthcare workers resonate with the emotional state of the patient, causing a robust aversive response within them known as empathic distress.1 Both secondary trauma and empathic distress, previously described as “compassion fatigue,” can negatively impact occupational performance and patient safety.2
Critical incidents which can be strongly aversive experiences, frequently occur within EMS workdays. Examples of critical incidents include line of duty deaths, suicides of colleagues, serious work-related injuries, multi-casualty disasters, acts of terrorism, witnessing violence, pediatric trauma, and other emotionally distressing events. Without proper mental preparation, critical incidents can result in empathic distress and secondary trauma. Left unaddressed, empathic distress and secondary trauma may lead to poor mental health or psychological and medical illnesses.3., 4., 5.
The effect of unmitigated secondary trauma and unmitigated empathic distress is far-reaching. Work-related stress not only possesses the capacity to cause more stress while at work but may also carry over outside of work.6 The work-related stress for EMS providers is unique, in that they are typically the first responders to critical incidents and tasked with the challenge of mitigating further harm. Among EMS providers in the United States, the mean score for work-related stress was consistently in the “high risk” range.7 Additional data on EMS providers across the United States supports that approximately 6% report high anxiety and 7% report depressive symptoms.8 Moreover, many EMS providers endorse that demographic and work-life characteristics directly result in depression, anxiety, and stress.8 Risky sequelae of untreated trauma may also include chronic alcohol use 9 and clinical depression.10 EMS providers who do not actively work to foster resilience when addressing occupational trauma may experience symptoms of post-traumatic stress disorder (PTSD). For example, the prevalence of PTSD symptoms is consistently high in EMS ambulance drivers, with approximately 20% of diagnosed with PTSD.4
Empathic distress can occur when one is emotionally depleted and unable to feel compassion. Those with a higher risk of empathic distress demonstrate irritability with patients, reduced standard of care, and increased likelihood of leaving the profession altogether.11 The adverse sequelae of empathic distress can result in impaired outcomes for both the patient and provider. Compassion which is a prosocial emotion has been demonstrated to foster positive affect, bolster immunological balance, and decrease the risk of mental illness.12., 13. It is therefore advisable for EMS agencies to invest in interventions that foster compassion and reduce empathic distress and secondary trauma.
Interventions to address stress in EMS providers have shown mixed results.14., 15. Many organizations have utilized a critical incident stress management (CISM) model in the aftermath of high-intensity events to build community and facilitate conversations. However, recent research demonstrates little evidence of a positive effect on post-traumatic stress or psychological distress 16 nor any preventive benefit.17., 18., 19. Several reviews have concluded that the CISM model is not appropriate for all traumas, especially when psychological trauma is not endorsed by individuals. Further, the use of CISM can inadvertently increase the risk of traumatization20 along with causing increased symptoms of hyperarousal, anxiety, and an overall decrease in the level of effective functioning.21., 22., 23.
Ameliorating the effects of trauma may more effectively begin with a focus on decreasing stress and improving wellbeing before the critical incident. Addressing stress and stigma in a non-shameful way is essential for promoting psychological growth.24 Recent research has revealed that EMS providers may prefer informal peer-support over CISM.25 Interventions that include peer support are some of the most efficacious in mediating the negative effects of adverse emotional events among clinicians.26 In short, it appears that social connectedness fosters compassion. When individuals engage in therapies and share experiences, they may be more likely to attend to their internal stressors and feel less shame about how they are feeling.27., 28.
Mindfulness has been defined as intentional nonjudgmental present moment awareness. A popular hypothesis relies on a two-component model of mindfulness involving self-regulation of attention on the immediate experience and recognition of mental events in the present moment.29 Mindfulness therapies have been demonstrated to foster attention and emotional awareness.30., 31. Among healthcare providers, mindfulness training, has been shown to be effective in reducing burnout and increasing job satisfaction, quality of life, compassion, patient satisfaction, and healthcare outcomes.32., 33., 34., 35., 36., 37., 38., 39., 40., 41.
In recent years, Mindfulness-Based Stress Reduction (MBSR) has been shown to be effective in fostering a sense of connectedness and compassion for others.42 This eight-week course focuses on fostering attention, awareness, resiliency, reframing, and applying these approaches to stress management. Following a similar model, a Mindfulness for Healthcare Providers course was developed at the University of Virginia.34 This program is modeled after the MBSR program and adapted for healthcare providers. Early results from our work have demonstrated improved mental health, reduced emotional exhaustion and depersonalization, and improved personal accomplishment among participants.34
Section snippets
Methods
We recruited individuals from a local rural volunteer EMS rescue squad to participate in a class called “Eight-Week Stress Reduction and Wellbeing (Stress and Wellbeing Course).” Members of this agency were recruited via personalized letters and emails. Participants with the longest history of membership with the rescue squad were given priority to participate. These individuals were selected as it was hypothesized they would have greater EMS experience and therefore increased exposure to
Demographics and pre-assessment
EMS providers (n = 40) were invited to join the Stress and Wellbeing Course. Of those invited a smaller group responded (n = 15) within two weeks confirming their ability to participate. The average age of participants was 46.43 years (SD = 17.2). Participants were 13 men and 2 women aged 26 to 73 years (men: M = 48, SD = 16.83). All except for one were advanced providers (medic, paramedic, or medical doctor). Of those who joined the class, three participants dropped out after the
The importance of compassion in EMS
In this study, we examined the impact of an intervention modeled on MBSR with an EMS population. Key findings include statistically significant changes in compassion satisfaction (CS), burnout (BO), and trait mindfulness (TM) that persisted for six months. This effect was most pronounced in compassion satisfaction (CS) and burnout (BO) subscales of the ProQOL. Before the study, all participants presented with low-risk CS scores (considerably above average), high-risk STS scores (significantly
Conclusion
The primary aims of this study were to demonstrate the feasibility and impact of a mindfulness intervention for community EMS workers. The participants of this study came from a broad variety of backgrounds, and each had significant experience in the field. The improvements in scores across this heterogeneous group suggest that this intervention may be beneficial to many populations.
Authors' contribution
DMD and JKP are responsible for the methodology. VAL obtained research resources and funding acquisition. DMD, JKP, and JFC supervised the trial. DMD was responsible for project administration, data curation, validated the trial, and was responsible for formal analysis. DMD drafted the manuscript, and all authors reviewed and edited the manuscript.
Acknowledgments
The authors thank Cawood Fitzhugh for co-leading meditation sessions. The authors would also like to thank the Charlottesville-Albemarle Rescue Squad for funding this study.
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EMS (Emergency Medical Service) providers constitute a vulnerable, understudied population. Often the EMS provider witnesses trauma and suffering which can lead to operational breakdown and psychological suffering, at times, leading to suicide. This article investigates empathic distress amongst EMS providers and novel methods to prevent burnout. This study is the first of its kind to investigate the psychological sequelae which lead to harm and investigate preventative, mindfulness-based interventions, which may limit suffering and foster wellbeing.