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 Post-traumatic stress disorder among paramedic and hospital emergency personnel in south-east Iran

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Sedigheh Iranmanesh, Batool Tirgari, Hojat Sheikh Bardsiri

 

School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran

 

Corresponding Author: Batool Tirgari, Email: hbardsiri@yahoo.com

 

© 2013 World Journal of Emergency Medicine

 

DOI: 10.5847/ wjem.j.issn.1920–8642.2013.01.005

 

BACKGROUND: Paramedic and emergency personnel may encounter directly many events that threat their own wellbeing during their daily work. This study was conducted to examine the prevalence rate of post-traumatic stress disorder (PTSD) among two groups of paramedic and emergency personnel in south-east Iran.

METHODS: The study employed a descriptive design and was conducted in four hospital emergency wards and a pre-hospital emergency base supervised by Kerman Medical University. Using Mississippi PTSD, we assessed the prevalence rate in paramedics (n=150) and emergency personnel (n=250).

RESULTS: The two groups had different levels of education, marital status, experience of traumatic events, work hours per month, and gender. Most (94%) of paramedic and hospital emergency personnel reported moderate PTSD. The two groups had significant different levels of PTSD in all subscale.

CONCLUSION: The study suggests that health care managers should organize systematic and dynamic policies and procedures in dealing with PTSD to assist both groups of personnel.

(World J Emerg Med 2013; 4(1): 26–31)

 

KEY WORDS: Post-traumatic stress disorder; Paramedic personnel; Emergency personnel

 

INTRODUCTION

Post-traumatic stress disorder (PTSD) is an anxiety disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress.[1] According to the report of the National Institute of Mental Health (NIMH), 7.7 million adults or 3.5 % of adult people suffer from PTSD.[2] Nayback[3] stated that PTSD may cause a wide spectrum of symptoms including flashbacks and nightmares of the event, anger, anxiety, depression, irritability, and impaired concentration. He continued that it also causes difficulty in sleeping, panic attacks, hyper vigilance and an exaggerated startle response. Hospitals are stressful places due to the increased complexity and demands of most job descriptions, the unpredictable changes in one's daily work routine, unrealistic expectations from patients/their families, and common encounters with ethical as well as end of life issues.[1,4] Mealer et al[5] identified that psychological symptoms including PTSD, anxiety, and depression are common in nurses. They go on that nurses who work in the outpatient setting are significantly less likely to have a diagnosis of PTSD when compared to inpatient nurses. All of the nurses who met diagnostic criteria for PTSD endorsed being exposed to a traumatic event including seeing patient death, massive bleeding, open surgical wounds, trauma related injuries, and performing futile care to critically or terminally ill patients.[5]

Earlier studies[6–8] showed that both paramedics and emergency department health care workers have been shown to be at increased risk of PTSD. Of all of the various types of hospital employees, nurses are often exposed to many of these stressors and may be predisposed to develop work-related psychological disorders such as symptoms of PTSD.[1] According to Mealer et al,[6] 25% of critical care nurses and 33% of emergency nurses had PTSD symptoms. They go on that critical care and emergency nurses had a higher incidence of PTSD symptoms compared with others. Studies[9,10] showed a prevalence rate of 20%–22% for PTSD among paramedic personnel. It was reported that factors such as age, sex, being unmarried and earlier experience of violence correlated with development of PTSD.[3,5,9–11] Mealer et al[5] found that years of nursing experiences, age of nurses, and how often a nurse is the charge nurse are significantly related to the prevalence of PTSD. In the Iranian context, no study was found to assess the prevalence rate of PTSD between paramedic and emergency personnel. Thus, paramedic and emergency personnel experience workplace events that present a direct threat to their own wellbeing (e.g., threatened and actual assault), and they are also confronted with events that involve sever injury.[4] This study was conducted to examine the prevalence rate of PTSD in both paramedic and emergency personnel in south-east Iran.

 

METHODS

Design

This study was approved by Kerman University of Medical Science prior to the collection of data. A descriptive cross sectional design was employed.

 

Sample and setting

A total of 400 paramedic and emergency personnel were included in this study. Emergency personnel selected from emergency wards of four hospitals Affiliated to Kerman Medical University (n=250). Paramedic personnel selected from pre-hospital emergency base of Kerman Medical University (n=150). Both paramedic and emergency personnel were given the same questionnaire evaluating post-traumatic stress disorder.

 

Background

A questionnaire was designed to assess such demographic data of participants as age, gender, marital status, education level, interest to work, job experience, direct contact with the patient, experience with traumatic events, and experience with loss of family members.

 

Questionnaire

Participants from both paramedic and emergency personnel completed standardized assessment instrument measuring post traumatic stress disorder. The Mississipi scale for post-traumatic stress disorder (M-PTSD) is a 39- item questionnaire. The items included four components: frequently haunted by memoirs (10 items 4, 7, 13, 14, 36, 39, 18, 29, 33, 37), problems in personal relationship (10 items 6, 22, 1, 5, 19, 28, 30, 35, 38), problems in controlling emotional feelings (10 items 3, 20, 26, 24, 27, 3116, 23, 25, 32), and lack of depression (10 items 8, 9, 10, 12, 15, 21, 2, 11, 17, 34). The response rate of items was based on 5-point Likert scale (never true=1, entirely true =5). The response rate of 10 items (2, 6, 11, 17, 19, 22, 24, 27, 30, and 34) ranged inversely (entirely true =1, never true =5). The total score varied between 0 and 195. The high score was indicative of severe PTSD. The score ranged between mild and severe (lower than 65 = mild PTSD; 65–130=moderate PTSD, and higher than 130=severe PTSD).

 

Validity and reliability

M-PTSD was validated on male veterans of the Vietnam War.[14] It has been considered a reliable (α Chronbach=0.94) and valid measure of PTSD in veterans exposed to combat.[15] In Iran, Goodarzi et al[16] checked validity and reliability of M-PTSD. They reported an acceptable reliability and validity for this questionnaire (internal consistency=0.92, external consistency=0.82).

 

Data collection and analysis

This study was approved by the Ethical Committee of Kerman University of Medical Science. All participants signed informed consent. Information about the study was given to the participants orally or in written form. Confidentiality was kept by putting no name or other personal information in the questionnaires. Questionnaires were handed out by the third author and distributed to the participants. The participants filled in the questionnaire during their daily work hours. About 85% of all questions listed in the questionnaire were responded. The data from the questionnaire were analyzed using the Statistical Package for Social Scientists (SPSS). Descriptive analysis was made to determine the characteristics of the sample. A Kolmogorov-Smirnov test was conducted to indicate that the data were sampled from a population with normal distribution. To check the homogeneity of the categorized demographic data (e.g. level of education, experience of traumatic events) between the two groups of personnel, the Chi-square test was used. The correlation between demographic data and PTSD mean score examined by the independent t test and one-way ANOVA. Student's t test was used to compare the two groups' mean scores in M-PTSD. Pearson's product-moment correlation coefficient was used to identify the relationship between age and posttraumatic stress disorder. The difference was statistically significant at level of P<0.05.

 

RESULTS

A Kolmogrov-Smirnov test indicated that the data were sampled from a population with normal distribution.

 

Demographic information

Participants' demographic characteristics are shown in Table 1. The mean age of paramedics was 29.27±5.98 years, and that of hospital emergency personnel was 31.23±6.33 years. In the emergency group, 68.4% were female, whereas in the paramedic group there was no female at all. In the emergency group, most participants were nurses with BSc. In the paramedic group, most participants (56%) had BSc. Among the paramedic group, 61.3% were married, whereas in the emergency group almost 77% were single. In the emergency group, 44.8% worked 150–200 hours per month. But in the paramedic group, 39.3% worked more than 200 hours per month. About 81.3% of paramedic and 88.4% of hospital emergency personnel had direct contact with patients. In the hospital emergency personnel, 34% had moderate experience in coping with traumatic events. In the paramedic personnel, 41.3% had rich experience in dealing with traumatic events. Almost half of participants in both groups had moderate interest to work.

 

Comparisons between the groups

The Chi-square test showed that the two groups had different levels of education, marital status, experience in dealing with traumatic events, work hours per month, and gender (Table 1). The descriptive analysis indicated that 94% of both paramedic and hospital emergency personnel reported moderate posttraumatic stress disorder. The two groups had a significant difference in all subscale scores of M-PTSD (P<0.001). The emergency personnel reported higher score of M-PTSD in all subscales than the paramedic personnel (Table 2).

 

Hospital emergency personnel

One-way ANOVA revealed a correlation between participants' educational level and M-PTSD score, indicating that hospital emergency personnel who had a bachelor degree are more likely to have PTSD (P=0.01) than their colleagues in the paramedic group. In addition, there was a correlation between job and PM-PTSD score, thus physicians compared to other participants had a higher score of PTSD (P=0.04). Furthermore, a negative correlation was found between working hours per month and M-PTSD score. This finding indicates that participants who work less than 100 hours per month, are more likely to have M-PTSD (P=0.001) than those who work 100–150 or more than 200 hours per month.

The independent t test showed a negative association between interest to work and M-PTSD score. This finding indicates that participants with low interest to work had a higher rate of PTSD (P=0.0001) than those with more interest to work. Furthermore, a correlation was found between direct contact with patients and M-PTSD score. Thus, those who had a direct contact with patients had a higher score of M-PTSD (P=0.009) than those who had no direct contact with patients. However, there was no significant correlation between M-PTSD score and gender, age, marital status, job experience and experience in dealing with disasters or trauma events (Table 3).

 

Paramedic personnel

One-way ANOVA showed that there was a correlation between job and M-PTSD score. Paramedic personnel who were nurses had a higher score of M-PTSD (P=0.01) than emergency personnel. However, there was no significant correlation between M-PTSD score and gender, age, marital status, education level, years in ambulance service, working hour per month, interest to work, direct contact with patients as well as experience in dealing with disasters and trauma events.

 

DISCUSSION

This study revealed a high incidence (94%) of post-traumatic stress disorder among paramedic and hospital emergency personnel. This finding is almost similar to that reported elsewhere.[5–8,10,17] Bennett et al[10] using M-PTSD found that among emergency medical technicians and paramedics, the overall rate of PTSD was 22%. Using the post-traumatic stress symptoms (PTSS) and M-PTSD, Mealer et al[5] found 22% of nurses had symptoms of PTSD, and 18% met diagnostic criteria for PTSD. Using M-PTSD assessed PTSD in emergency workers at a major hospital in a large urban center in British Columbia, Laposa and Alden[17] found that 20% of participants met the formal diagnostic criteria for PTSD, and 20% met the PTSD symptom criteria. In Iran, Narimani et al[12] reported that 14% of hospital emergency nurses and 8% of fire department workers were diagnosed with posttraumatic stress. By assessing PTSD among emergency medical technicians in Iran, Saberi et al[13] also found that considering DSMIV criteria, 36.4% of participants met the PTSD criteria. Using impact of event scale (IES), they found a trauma sever impact among 28.9 % of emergency personnel. According to Alden et al,[4] emergency workers are trained to manage medical emergencies and expect to encounter death and serious injury by the very nature of their jobs. They have to increase their emotional preparation and perceive control over these events, and therefore are at risk for PTSD.

According to the results, the prevalence rate of PTSD is significantly higher than that in similar studies conducted in the other countries. One explanation could be that the instruments and sample size used by earlier studies are different from those used in the following studies, and the results subsequently become different. It could also be related to the difference in organizational structures in different countries, the different level of integrity in response to questions, and different methods of their selection, level of education, and working volume.[18] Therefore, paramedic personnel may encounter many patients who have severe trauma caused by traffic or other accidents. Hospital emergency personnel are daily involved with a lot of cases of severe trauma.

Hospital emergency personnel had a higher mean M-PTSD score than paramedic personnel. However, this difference was non-significant in the study by Mealer et al.[19] The difference may be related to the level of education in both groups. In the Iranian health care system, paramedic personnel must receive special emergency education for two years, whereas hospital emergency personnel are not specifically educated in emergency medicine. They ultimately take part in one to two courses on emergency medicine including trauma management during their education. Additionally, hospital emergency personnel have more pre experiences in dealing with traumatic events than paramedic personnel. Such experiences may positively infl uence on the development of PTSD.

Working hours per month may be correlated with M-PTSD score. Hospital emergency personnel who worked less than 100 hours per month reported a higher M-PTSD score than other personnel. It is indicated that the more working hours per month, the lower prevalence rate of PTSD. This could be due to the amount of adaptation obtained by the hospital emergency personnel. The personnel who had more shifts and spent more time in emergency department gain more adaptation with PTSD than those who spent less time in such department. The results of this study also indicate that hospital emergency personnel who are physicians had a higher score of M-PTSD than other participants. Palgi et al[20] found that among hospital emergency personnel, physicians and nurses had higher M-PTSD scores than other personnel. Moreover, using Impact of Event Scalerevised (IES-R) and Center for Epidemiologic Studies- Depression scale (CES-D), Ben-Ezra et al[22] found that both nurses and administrative staff had a significantly higher risk for clinical symptoms of PTSD compared to physicians. As it is mentioned above, working hours per month are negatively correlated with the prevalence rate of PTSD. In the Iranian health care system, physicians have the least shifts compared to other personnel. This may cause less adaptation and higher risk for PTSD.

Based on the findings, paramedic personnel who are nurses have a higher score of M-PTSD compared with other groups of personnel. Lavoie et al[21] reported a high risk of PTSD among nurses. Mealer et al[19] also found that critical care and emergency department nurses have a higher incidence of PTSD symptoms compared with others. They asserted that as many as 25% of critical care nurses and 33% of emergency nurses are positive for symptoms of PTSD. Of all of the various types of hospital employees, nurses are often exposed to many of these stressors and may be predisposed to develop work-related psychological disorders such as symptoms of PTSD.[1] The results of this study indicate that no significant correlation between the number of years for ambulance duty and mean M-PTSD score in paramedic personnel. In contrast, Jonsson et al[23] asserted that there is a strong connection between the number of years in ambulance service and PTSD symptoms. In Iran, paramedic service is almost a newly established practice in the health care system. During their years of practice, paramedics receive no additional academic or clinical education about adaptation with PTSD. Therefore, practice has no influence on their prevalence rate of PTSD.

In conclusion, the results of this study indicate a high incidence of PTSD among paramedic personnel and hospital emergency personnel in south-east Iran. Thus health care managers are required to set up systematic and dynamic policies and procedures in order to assist both groups of personnel in dealing with PTSD. A continuing educational program on adaptation with PTSD could be somehow helpful. A screening or specific selection method to recognize high-risk individuals, particularly those who want to work in emergency departments could be another way. Rotation and exchanging personnel between different wards may provide emergency staff an opportunity to experience the wards with a lower workload compared to the emergency wards, and therefore improve their strength. Giving some special rewards to paramedic and emergency hospital personnel may also motivate them to find the ways to be adapted with their PTSD symptoms. Creating a reflective narrative environment, in which paramedic and emergency personnel can express their own feelings and experiences about stressful situation, seems to be as an effective approach to identify the influential factors on PTSD.

Our study has several limitations. The sample of participants, which is not representative of all paramedic and emergency personnel, could deteriorate the generalization of the findings. Use of self-report questionnaires may lead to an overestimation of some of the findings due to variance. Another limitation is limited time that participants have to fill in the questionnaire. Dealing with this limitation, the second author asked participants to fill in the questionnaire whenever or wherever they preferred.

 

Funding: None.

Ethical approval: This study was approved by the Ethical Committee of Kerman University of Medical Science.

Conflicts of interest: The authors declare they have no conflict of interest.

Contributors: Iranmanesh S proposed the study and wrote the paper. All authors contributed to the design and interpretation of the study and to further drafts.

 

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Received October 6, 2012

Accepted after revision January 19, 2013

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