Paramedic: The Importance of Stress Resistance in Providing Medical Care

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 Paramedicine practice involves administering emergency treatment to patients, which can also require the skill of providing grief support to patients and families. The nature of this medical specialty means that paramedics need to manage grief and stress efficiently or risk suffering detrimental physical, emotional, and social repercussions for themselves and the bereaved. Jakoby states that grief is an emotion experienced in response to losing a valued relationship which differ across cultures. Given the multicultural individuals in society that paramedics can encounter, it is important to have an understanding of cultural differences to assist grieving patients and families. Additionally, prior to exposure to grief, paramedics must manage their personal stress to preserve their personal well-being and competency as health professionals.

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Paramedics are consistently exposed to situations that can be mentally, physically, and emotionally demanding. Kutowski, King & DeLongis state that paramedics are subsequently at a greater risk of experiencing mental health issues like post-traumatic stress disorder (PTSD), anxiety, or ‘burnout’. Mariotti states that when a human encounters stress, cortical centers in the brain activate the adrenal glands via the sympathetic nervous system. This stimulates adrenaline and glucocorticoid hormones to be secreted, increasing the cardiac and respiratory rate. However, when stress becomes chronic, receptors controlling stress hormones become impaired, compromising the immune system and damaging cardiac and nervous tissue. Aehlert states that the physical presence of stress varies between individuals, but can include feeling overwhelmed, panic attacks, palpitations, and memory problems. In paramedicine, occupational factors such as traumatic incidents like witnessing mass casualties, exposure to injury, death, and being threatened can induce stress in paramedics. Furthermore, shift work has been suggested by Courtney, Francis, and Paxton to be a significant influence in occupational stress among paramedics. They state that shift work can increase levels of fatigue, poorer sleep, lack of exercise, and anxiety. The social repercussions of occupational stress among paramedics were evident in the DeLongis, Holtzman, Puterman & Cam study. It was found that paramedics can struggle to separate work-related stress from home life, resulting in poorer communication with partners, with a drawl, and relationship issues. The Ryburn study portrays this among Auckland St. John paramedics, where a paramedic commented on their colleagues experiencing domestic unrest due to work-related stress. Furthermore, the stress involved with paramedicine has led to the development of culture among some paramedics believing that they can manage anything. This negative cultural impact of stress has led to some paramedics of being afraid to seek help from management when experiencing stress. According to some of the St. John paramedics, they feared being perceived as weak by seeking stress-related help and losing their jobs. Furthermore, this culture can also lead to performance-anxiety-related stress among paramedics in order to achieve the perceived expectation of their colleagues. Filstad and McManus state that this involves showing resilience during adversity in order to be accepted into a ‘brotherhood’.

Beer, Bowling & Bennett support this, stating that emergency service members often follow the cues of their fellow crew members and staff when it comes to managing stress.

Strategies to help maintain the personal well-being of paramedics

There are various strategies and support systems that a paramedic can use to mitigate the adverse implications of stress. Aehlert states that poor mechanisms of dealing with stress can include venting with anger, tobacco, alcohol, and substance abuse, all of which offer short-term relief and can have negative consequences. Mistovich and Karen propose that making lifestyle changes and maintaining balance are key factors to prevent stress accumulation. These methods include exercising regularly, maintaining a healthy diet, meditating, and spending time with loved ones by requesting certain shifts. Strategies for paramedic shifts could include the visualization technique to allow the paramedic to mentally reframe, positive self-deep breathing to lower the heart and adrenaline rates, and humor, which helps as an anxiety release and increases morale. 

A New Zealand paramedic can also manage their stress by seeking assistance from administrative support, such as a cell line and through critical incident stress debriefing. This involves paramedics discussing their feelings and receiving advice for conquering their stress to allow them to return to service. When compared to other New Zealand health sectors, other health practitioners like doctors or midwives are also offered helplines and counseling services, through organizations such as the Australasian College of Surgeons and the Medical Protection Society (MPS). MPS for example works alongside the New Zealand College of Clinical Psychologists to provide counseling to health professionals experiencing stress. Furthermore, district health boards (DHB’s) often provide services to their employees. For example, on-site services for health workers are available at the Auckland, Counties-Manukau, and Waitemata DHB’s.

Le Badour and Bergeron state that paramedics frequently deal with terminally ill patients and death. Thus, it is essential that paramedics understand the characteristics associated with the grief process to those involved. A popular grieving theory is a Kubler-Ross model, detailing an individual’s experience with grief moving through denial, anger, bargaining, depression, and acceptance. Bowlby’s theory draws similarities to Kubler-Ross, where Bowlby describes how one must ‘reorganize’ and ‘recover’ in acceptance of loss. However, Stroebe criticizes the Kubler-Ross model for its simplicity, arguing that grieving is not linear and people experience different emotions throughout the process. A model that supports this claim is the ‘pinball model’. This theory acknowledges grief’s complex, chaotic and un-linear nature, seeing individuals ‘pinball’ from various emotions as they grieve. The difference between this theory and Kubler-Ross is that it could enable the paramedic and bereaved to recognize grief’s irregularities. Bledsoe, Porter, and Cherry support this, stating that people facing grief behave differently. Depending on the emotion that the patient is experiencing, the pinball model could be effective in allowing paramedics to understand what the bereaved are experiencing and better adapt to assist with their grief. Furthermore, Athan, Pathak, and Thompson state that there is pressure for paramedics to perform in healthcare settings, which could mean that when a patient dies, reactions like anger could endanger the paramedic. By recognizing differing stages of grief, such as in Kubler-Ross, a paramedic could anticipate certain emotions and act accordingly to prevent further negative outcomes.

Delivering a death notification is a highly difficult and stressful situation that paramedics encounter. If a paramedic manages grief poorly with an incompetent death notification, the receivers can respond with dissatisfaction and cause further grief during a difficult time. To help avoid this, a paramedic can use the ‘GRIEV_ING’ strategy, a mnemonic involving several steps with delivering tragic news to begin the grieving process. Back, Arnold and Tutsky state that additional strategies that a paramedic can include using simple terminology, responding accordingly to the receiver’s emotions, and gaining prior knowledge of cultural beliefs to uphold cultural sensitivity to assist with the grieving process. Families practicing cultural methods may behave differently when encountering death. This means that cultural competence is important for protecting the bereaved from emotional and spiritual harm. For example, some cultures wish to stay in contact with a loved one following death. This can be seen with Maori, where tribes and whanau gather to grieve with the body in the marae for several days. As a paramedic, to help with the Maori grieving process, Mead states that the tupapaku (body) should be placed in the traditional prone position. Furthermore, the paramedic could place water outside the ambulance or room, as visiting whanau ‘cleanse’ themselves to not breach ‘tapu’ after exposure with the deceased. In other cultures, it is believed that the spirits of the dead are able to be among the living. This can be seen with American Navajo, who in order to not summon the person’s soul, refrain from speaking the name of the deceased individual. To assist with the Navajo grieving process, a paramedic could minimize the mention of the deceased person’s name to the family. For paramedics to comprehensively understand cultural grieving processes, however, can be difficult, given the diversity paramedics will encounter. This could also lead to a paramedic’s failure to manage the grief the individual may be experiencing, resulting in further emotional harm for the bereaved and possible litigations against the paramedic.

Conclusion

Stress and grief are realities of paramedicine practice. Therefore, it is essential that paramedics have effective measures in place to prevent stress from overwhelming them, causing physical, social, and cultural harm, whilst ultimately impinging their ability to implement high-quality care to patients. Furthermore, it is important for paramedics to understand grieving and the variations involved with it across different cultures. Inefficient handling of grief can result in detrimental implications for the paramedic and for the bereaved. By carefully managing stress and grief, a paramedic will be able to function at an optimum level, resulting in better outcomes for all involved.  

24 May 2022

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