TOC o “1-3” h z u Abstract PAGEREF _Toc358825046 h 31.0Introduction PAGEREF _Toc358825047 h 52.0Literature Review PAGEREF _Toc358825048 h 53.0Methodology PAGEREF _Toc358825049 h 8Research Design PAGEREF _Toc358825050 h 8Sampling Method PAGEREF _Toc358825051 h 8Data Collection Method PAGEREF _Toc358825052 h 9Ethical Considerations PAGEREF _Toc358825053 h 114.0Results and Findings PAGEREF _Toc358825054 h 12Positive work effects PAGEREF _Toc358825055 h 12Stress factors PAGEREF _Toc358825056 h 12Effects of stress PAGEREF _Toc358825057 h 135.0Discussion PAGEREF _Toc358825058 h 146.0Recommendations PAGEREF _Toc358825059 h 167.0Conclusion PAGEREF _Toc358825060 h 17References PAGEREF _Toc358825061 h 18APPENDICES PAGEREF _Toc358825062 h 20Appendix 1: Interview Guide for the Respondents PAGEREF _Toc358825063 h 20Apendix 2: Preliminary Data Analysis PAGEREF _Toc358825064 h 20Apendix 2a: Preliminary Data Analysis – Interview 001 PAGEREF _Toc358825065 h 20Apendix 2b: Preliminary Data Analysis – Interview 002 PAGEREF _Toc358825066 h 26Apendix 2c: Preliminary Data Analysis – Interview 003 PAGEREF _Toc358825067 h 30Apendix 2d: Preliminary Data Analysis – Interview 004 PAGEREF _Toc358825068 h 35Appendix 3: Thematic analyses PAGEREF _Toc358825069 h 41Appendix 4: Face Sheets PAGEREF _Toc358825070 h 45Appendix 4a: Face Sheet 001 PAGEREF _Toc358825071 h 45Appendix 4b: Face Sheet 002 PAGEREF _Toc358825072 h 45Appendix 4c: Face Sheet 003 PAGEREF _Toc358825073 h 46Appendix 4d: Face Sheet 004 PAGEREF _Toc358825074 h 46Appendix 5: Ethics Form A PAGEREF _Toc358825075 h 47Appendix 5: Ethics Form B PAGEREF _Toc358825076 h 79

AbstractThis study aimed to establish the effects that stress had on the motivation, morale and overall performance of Paramedics. It sought to establish the relationship that existed between these causes and the effects. The study was descriptive in nature and aimed at exploration of experiences, views, perceptions and observations. Qualitative data collection methods were adopted and the researcher used one on one interviews. The population was defined as paramedic students in Flinders University who had worked in Saudi Arabia, and involved a sample of four purposively selected respondents. The study found that although paramedics feel motivated by adequate training and service to people, a wide range of factors contributes to them getting job related stress. These factors include work overload, long working hours and poor channels of communication among others. The research also established that stress causes reduced performance, low morale and increased rate of absenteeism among paramedics. The study concludes that stress in paramedicine comes from many sources and all stakeholders are contributors as well as victims of the stress. It then goes ahead and suggests some ways in which stakeholders can reduce the causative agents of stress.

1.0IntroductionWork related stress is a well-known phenomenon in many professions. However, some professions are more prone to it than others. Paramedicine, by its very nature, is among the professions with the highest risks of stress and its many manifestations. Extensive research has been carried out on stress, its characteristics and effects on paramedics (McFarlane, Williamson and Barton, 2009).

This research aimed at addressing itself to the causes of stress in paramedics and the effects it has on their morale, motivation and performance. The study approached the issue on a causal – effect theory with the aim of determining how the paramedics felt the various factors that they feel predispose them to stress would affect their overall on-the-job performance. The study also sought to fill a gap left by other studies in that it did not draw its own recommendations but will sought to gather these from the paramedics themselves thereby emerging with home-grown solutions for Paramedics problems.

2.0Literature ReviewStress has been found to heavily affect the level of employee output.

Data Analysis & Presentation

To analyse the research data collected, preliminary data analysis (Appendix 2) and then thematic analysis (Appendix 3: Thematic analysis) approach were used. Preliminary analysis involves studying the obtained patterns of responses or observations from the respondents (Grbich 1999). In this case, the transcripts prepared from the interviews and the obtained findings based on the responses given by the respondents were presented through the use of the descriptions given by the respondents during the interview and in response to the asked questions.

Thematic analysis is an important analysis tool in qualitative research since it identifies the implicit and explicit concepts captured in collected data. It puts its emphasis on the description and organisation of a data set. The method can be used inductively or deductively and the researcher opts on the application depending on the epistemology of their study (Boyatzis, 1998). Since the data collected was intact, the researcher used the Block, group and label approach to thematic analysis. The first step involved identifying which among the collected data was relevant to the research (Corbin and Strauss, 2008). Next, the researcher used the Preliminary Data analysis sheets a (Apendix 2) to group the data into columns and used it to prepare the thematic analysis sheets (Appendix 3).

Ethical Considerations

It is important to note that the sampling process, piloting and actual data collection processes were conducted informally and with the verbal consent of participants. For the purpose of observation guidelines, the researcher sought the approval of the Social and Behavioural research ethics Committee (Apendix 2: Ethics form)

As the data collected during this study contains very sensitive and personal information, all participants were assured of total confidentiality, anonymity and guaranteed that the findings of this research shall not cause them any professional or reputational harm whatsoever (Mantri 2009; Grbich 1999). It was important for the researcher to identify the possible harm or damage, both personal and professional, which could be caused on the participants if any of the information given was traced back to them. Finally, the findings of this result were used and disseminated exclusively for academic purposes.

4.0Results and FindingsMajority of the participants in the research were practicing paramedics seeking further education in medical related fields. The data was organised into face sheets (Appendix 4). Four themes were identified in the description of the available data and labelled, positive work aspects, stress factors, stressor effects and possible solutions. The participants provided concise information for the different themes identified. They discussed their work experiences and identified numerous challenges which faced them when undertaking their duties as paramedics.

Positive work effectsThis theme aimed at capturing the specific elements inherent in the work that boosted the morale of the practitioners. The participants identified factors including adequate training which made feel them competent enough to offer the services required to them. The most prevalent motivation under this theme though was the service to the people angle with 75% of the respondents saying that they derive satisfaction from having saving lives or assisted a person in need of medical services. As Respondent number two put it,

“Most people in Saudi Arabia cannot access medical care . . . . . . . being able to serve people so desperately in need of medical care is inspiring.”

Stress factorsThe aim of this theme was to establish the various factors that paramedics consider as the major causes of job related stress. This was the main theme of the research. It emerged that a wide range of factors contribute to stress in the workplace. Huge workload was the most prevalently mentioned source of work related stress with 75% of the respondents mentioning it directly or mentioning some of its causes. The workload was said to be caused by understaffing, terrorism and violence. Another cause of stress which was mentioned by 50% of the respondents was long work hours which lead to burnout. Poor communication channels were also cited as a factor leading to stress. The respondents also mentioned Traffic congestion, lack of crowd control mechanisms and the ever increasing threat of malpractice litigation as factors that interfere with their work reducing efficiency which then interprets to frustration and stress.

Figure 1: Causes of stress among Saudi paramedics

Effects of stressThe respondents were unanimously (100%) agreed that the major result observed on stressed paramedics is reduced morale and motivation. This was also indicated to result in reduced efficiency and productivity by 75% of the respondents. 50% of the respondents said that a stressed paramedic was prone to errors. In the long run, the respondents (75%) indicated that stress takes its toll on the health of the individual which directly results in absenteeism and higher incidence of elongated sick leaves.

5.0DiscussionThe toll that work related stress and burnout takes on the psyche, motivation and morale of paramedics cannot be gainsaid. The daily encounters in their operations leave indelible marks on the paramedics’ psychological state (Clohessy and Ehlers, 1999). As enumerated by the previous studies analysed in the literature, this affects not only the paramedics but also the society in terms of resources needed to replace paramedics and the opportunity cost of losing one. McFarlane, Williamson and Barton (2009) draw a correlation between the factors to dissatisfaction, errors and decreased attention to patients. The characteristic responses to these factors as have been shown in the studies rhyme with those listed by Vettor and Kosninski (2000). These include emotional exhaustion, depersonalization and negative assessment of oneself.

Coping theory has been identified as the most effective way of dealing with the problem. The theory involves two broad types; problem and emotion focused coping. Problem focused coping involves exerting effort in the solution or management of the problem which resulted in the distress. Kilburn and Whitlock (n.d) explains that with this approach, the focus is in the assimilation relevant information to assist in planning and making decisions aimed at resolving the differences. On the other hand, emotional focused coping focuses on the alleviation of the emotional distress by adoption of cognitive processes like positive attitude, emotional support or stop gap measures like smoking and alcohol (Kilburn and Whitlock, n.d.).

The use of peer support in helping the victims has been identified as one of the most effective tools in dealing with affected workers. Okada et al (2007) has suggested that the individuals can be guided towards a positive coping mechanism like the adoption of beneficial hobbies like exercising rather than alcohol and smoking. Pre service training on stress management and coping has also been suggested as an essential tool to ward off possibilities of having to deal with adverse effects of stress in the future.

However, as shown by Robinson (2002), it is not all doom and gloom, the improvement in levels of stress management from the 1993 levels if well build upon can be enhanced. Further research is therefore necessary to identify the factors that have led to this improvement with an aim of capitalising on them. This would greatly benefit the paramedicine profession by retaining more employees and at a higher efficiency and motivation level. This would in turn ease the pressure on resources and also ease the resources for other improvement areas in the profession.

6.0RecommendationsStress and its causes are not quantifiable or easy to separate. It is thus recommended that the best way to deal with stress is to first and foremost tackle its causes. The researcher sough suggestions from the respondents on what they would recommend and the suggestions were as varied as were the causes. What emerges as the recurrent theme is that all stakeholders have a role to play in this. It is therefore recommended that the policy makers endeavour to make adequate staffing to ease the workload on paramedics, shifts should also be reviewed so as to make a balance between the available staff and fatigue levels. It would also help if proper communication channels were established through which two way information would flow swiftly. Civic education would also play a great role in avoiding crowd interference in scenes.

The government should also establish legal assistance programs for Paramedics against wrongful malpractice litigation. On the other hand, it is upon the paramedics themselves to change their attitudes towards some factors and ways of coping. As noted earlier, some people adopt proactive product focused coping mechanism which differs a lot from the reactive emotion focused mechanism. The management should also organise counselling sessions for the paramedics and make arrangements for debriefings after traumatising assignments and experiences.

7.0ConclusionThough the research cannot be said to be entirely indicative of the entire paramedicine field owing to its limited target population and the small sample size explored, it nevertheless points to a justifiable conclusion that stress is a formidable risk in the profession. The stress as described from the respondents emerges from many aspects of the field including the practice itself, the administration as well as personal attitudes of the paramedics themselves.

All stakeholders can therefore be said to be the source as well as victims of the effects of the stress with the authorities having to contend with increased pressure on resources needed to alleviate the effects on the paramedics and the patients. The wider population has also been shown to contribute to stress through frustration and as consumers of the services they become victims of the stress when the quality of services offered becomes compromised. The paramedics too contribute to stress through negative attitudes and coping mechanisms that are not proactive which end up complicating the matter further.

It is therefore not farfetched to say that the cyclic nature of stress factors could continue in perpetuity unless concerted efforts are made by all concerned to break the vicious cycle.

ReferencesBlau, G, Chapman, S & Gibson, G 2011, ‘Exploring the Importance of Different Items as Reasons for Leaving Emergency Medical Services Between Fully Compensated, Partially Compensated, and Non-Compensated/Volunteer Samples’, Journal of Allied Health, vol. 40, no. 3, pp.e33-e37.

Boyatzis, R. 1998. Transforming qualitative information: Thematic analysis and code development. Thousand Oaks, CA: Sage.

Clohessy, S & Ehlers, A 1999, ‘PTSD symptoms, response to intrusive memories and coping in ambulance service workers’, British Journal of Clinical Psychology, vol.38, pp.251-265.

Corbin, J. and Strauss, A. 2008. Basics of Qualitative Research 3rd Ed. Sage: Thousand Oaks, Ca.Top of Form

Glanz, K., Rimer, B. K., & Lewis, F. M. 2002. Health behavior and health education: theory, research, and practice. San Francisco, Jossey-Bass.Bottom of Form

Grbich, C 1999, Qualitative Research in Health: An Introduction, Allen & Unwin, NSW.

Kilburn, E & Whitlock, J n.d., ‘Coping’, Cornell Research Program on Self Injurious Behavior in Adolescents and Young Adults, viewed on 6 September 2012, <http://www.crpsib.com/userfiles/File/Coping%20Lit%20Review.pdf>.

Kumar, R 2008, Research Methodology, APH Publishing Corporation, New Delhi.LeBlanc, V, MacDonald, R, McArthur, B, King, K, &Lepine, T 2005, ‘Paramedic Performance in Calculating Drug Dosages Following Stressful Scenarios, Prehospital Emergency Care, vol.9, no.4, pp.439-444.

Mantri, J 2009, Research methodology on data envelopment analysis, Universal Press, Florida.

McBurney, DH & White, TL 2009, Research Methods, Cengage Learning, London.McFarlane, A, Williamson, P & Barton, C 2009, ‘The Impact of Traumatic Stressors in Civilian Occupational Settings’, Journal of Public Health Policy, vol.30, no.3, pp.311-327.

Nirel, N, Goldwag, R, Feigenberg, Z, Abadi, D & Halpern, P 2008, ‘Stress, Work Overload, Burnout, and Satisfaction among Paramedics in Israel’, Prehospital and Disaster Medicine, vol. 23, no.6, pp.537-546.Okada, N, Ishii, N, Nakata, M & Nakyama, S 2005, ‘Occupational Stress among Japanese Emergency Medical Technicians: Hyogo Prefecture’, Prehospital and Disaster Medicine, vol. 20, no. 2, pp.115-121.

Robinson, R 2002, ‘Follow-up Study of Health and Stress in Ambulance Services of Victoria, Australia, Victorian Ambulance Crisis Counselling Unit, Report 1, pp.1-54.

Vettor, S & Kosninski, F 2000, ‘Work-stress burnout in emergency medical technicians and the use of early recollections’, Journal of Employment Counselling, vol. 37, no.4, pp.216-228.

APPENDICESAppendix 1: Interview Guide for the RespondentsTell me a little about your work as a paramedic prior to study in Australia?

Probe: How many years working

What was the most positive aspect of working as a paramedic in Saudi Arabia?

What do you see as the main causes of stress for Saudi paramedics?

How do these stressors effect the operation (efficiency) of paramedics?

Probes: days of sick leave?

Probes: morale?

What could the administration or management at the various Emergency Centres do to lower the levels of stress experienced and to deal with their resultant effects?

Has your study in Australia helped with how you can manage stress when you return to paramedic practice?

Apendix 2: Preliminary Data AnalysisApendix 2a: Preliminary Data Analysis – Interview 001Research Question: How does stress affect the operation of paramedics?

Methodological notes Transcript 1 Preliminary Data Analysis

Questions well answered

Respondent does not mainly identify factors directly related to the health unit. More focused on Stress with regard to Saudi Arabia. Interviewer: Tell me a little about your work as a paramedic prior to study in Australia, Like, how many years did you work?

Int 001: Prior to my study in Australia, I worked as a paramedic in Saudi Arabia, which is my native country. I worked as a paramedic based in ambulances within the Saudi capital of Riyadh for seven years.

Interviewer: Do you have any speciality?

Int 001: Within the environment I worked, we normally responded to minimal emergency cases offering limited services in emergency situations.

Interviewer: What was the most positive aspect of working as a paramedic in Saudi Arabia?

Int 001: The training offered to paramedics in Saudi Arabia remains the most positive aspect of working as a paramedic within the country. This training has significantly improved my working capability as a paramedic and offered me an opportunity to enjoy being a paramedic. Though the job has many challenges, training has significantly improved my capacity to handle the various challenges I face during my working period.

Interviewer: What do you see as the main causes of stress for Saudi paramedics?

Int 001: There are many stressing factors while working as a paramedic in Saudi Arabia. The cities are normally characterized with constant traffic congestions, which prevent paramedics from reaching their destinations quickly. During emergency response like ambulances, failure to reach patients in time could be seen as inefficiency of paramedics. The delays resulting from traffic congestion stresses paramedics greatly. Another stressing factor, applying to accident scenes, is the presence of crowds of people on accident scenes. These individuals make it difficult for paramedics to reach the people requiring medical assistance.

Interviewer: How do these stressors effect the operation (efficiency) of paramedics? What effect do they have on your morale and sick leave days?

Int 001: When paramedics encounter these stressing factors, pressure normally increases on their side in offering sufficient services. Delays caused by traffic congestion, could reduce the time available for paramedics to attend to emergency calls. This might mean the paramedics work quickly and efficiency of their services could become compromised. Working under strict time deadlines within the profession becomes dangerous and the paramedics become prone to errors. The morale of paramedics working under these circumstances becomes immensely reduced because of the pressure and limited time available for attending patient. This remains so because paramedics remain aware of consequences which might follow erroneous operation. The paramedics can be held responsible if patient suffer damage as a result of delayed response.

Interviewer: What could the administration or management at the various Emergency Centers do to lower the levels of stress experienced and to deal with their resultant effects?

Int 001: The administration at various emergency centers should seek to change the methods applied in estimating the time required to make an emergency call response. Consideration should be undertaken based on various regions in order to cater for delays resulting from traffic congestion within city roads. The administration should seek to establish a government sponsored program aimed at informing the population about the necessary steps to take in accident scenes. With increased knowledge, people would not crowd around accident scenes in order to see paramedics perform their duties.

Interviewer: Has your study in Australia helped with how you can manage stress when you return to paramedic practice?

Int 001: Studying in Australia has offered me with efficient information regarding management of the stressing factors, upon returning to paramedic practice. The study has significantly improved my capacity to remain focused on delivering essential services and effectively minimizing the influence of external factors like crowds. The study has significantly enhanced my understanding that crowds must always be there as they are the people who normally call for assistance under these situation. This study has also enlightened me with the knowledge that these factors are also available in other counties, and their management could surmount to successful paramedic career.

Has previous paramedic experience before current study

No specialization

Stress among paramedics

External factors

Limited time to meet strict deadlines.

Increased workload and fatigue

Reduced morale and motivation to work

Role of the administration in reducing stress levels

Effective communication channel as a possible solution.

Public Education

Paramedic study in Australia is beneficial in reducing stress levels among paramedics.

Apendix 2b: Preliminary Data Analysis – Interview 002Research Question: How does stress affect the operation of paramedics?

Methodological notes Transcript 1 Preliminary Data Analysis

Questions well answered

Relevant answers given

Respondent attentive and keen on answering all questions

Interviewer: Tell me a little about your work as a paramedic prior to study in Australia, Like, how many years did you work?

Int 002: I have been working as a paramedic for five years now; this will be my sixth year.

Interviewer: Do you have any speciality?

Int 002: No I do not have any special training I am just a general paramedic.

Interviewer: What was the most positive aspect of working as a paramedic in Saudi Arabia?

Int 002: I could say the most positive aspect of working as a paramedic in Saudi Arabia is the fact that I have to handle many people who are critically sick. Most people in Saudi Arabia cannot get access to medical care. The people are often desperate to get medical attention. Being able to efficiently serve people who are so desperately in need of medical care is positive aspect.

Additionally, and contrary to what people might think there is adequate equipment to be used by paramedics in Saudi Arabia. Most people often think that there is lack of equipment in Saudi Arabia but this is not the case. As a matter of fact, there is high class equipment available for use. This is a very positive aspect when working as a paramedic in Saudi Arabia as I have all the equipment I need at my disposal.

Interviewer: What do you see as the main causes of stress for Saudi paramedics?

Int 002: There are various causes of stress for paramedics in Saudi Arabia, and none of them can be pin pointed as being the main cause. Attending to emergency cases that involve issues like accidents or terrorist/ violent attacks, whereby, the patients are in too much agony and pain is a real stress factor for many paramedics in Saudi Arabia. There are also cases of patients’ deaths which paramedics have to deal with. Such deaths occur regularly if not daily. It particularly becomes stressful when they have to break such bad news to the family and friends of the deceased.

Interviewer: How do these stressors effect the operation (efficiency) of paramedics? What effect do they have on your morale and sick leave days?

Int 002: These stressors have an impact on the paramedics in that they often extend the days of sick leave as they need time to deal with the stress. Stress is detrimental to the human body and it leads to increase in blood pressure. It also leads to decrease in the immune system and hence the paramedics can develop a weakness in their natural ability to fight bacteria and viruses. This leads to occurrence of sickness and they have more days of sick leave.

Interviewer: Any effect on ones morale?

Int 002: Oh! That? Stress definitely leads to low morale especially stress caused by death since the paramedics consider themselves as being failures when patients die under their care.

Interviewer: What could the administration or management at the various Emergency Centres do to lower the levels of stress experienced and to deal with their resultant effects?

Int 002: The administration can come up with employee assistance programs which can make counsellors and other specialists accessible for the employees. These specialists can assist the paramedics in the management of their stress. They can also provide debriefing sessions for the paramedics in cases of violence or traumatic events

Interviewer: Has your study in Australia helped with how you can manage stress when you return to paramedic practice?

Int 002: Yes, my study in Australia has really been of great help. I will surely apply what I have learned in Australia when I return to Saudi Arabia, and I am sure I will be able to manage any stress that I will encounter there.

Prior 5 years working experience

No specialization

Service to others and self satisfaction

Facilities and equipment available for efficient operation.

Stress factors

Witnessing the Intense pain and death of patients during emergency cases identified as major stress factors.

Impact of stress on the health of the paramedic results into extended sick leave days.

Reduced morale and encouragement

Role of the administration in reducing stress levels

Counselling and debriefing of paramedics for stress management

Public Education

Paramedic study in Australia is beneficial in stress management.

Apendix 2c: Preliminary Data Analysis – Interview 003Research Question: How does stress affect the operation of paramedics?

Methodological notes Transcript 1 Preliminary Data Analysis

Questions well answered

Relevant answers given

Question well and deeply answered

Answer too brief: More information was necessary

Interviewer: Tell me a little about your work as a paramedic prior to study in Australia?

Int 003: Generally, the work involved a 24hour system of emergency response. Each day would come with its own challenges, and the need to do a good job always imposed a lot of pressure on our service delivery as paramedics. Besides, working in Saudi Arabia meant that we had to go an extra mile to meet the best expectation of every patient and majority of them would complain even for very minor issues simply because they felt that they deserved more attention than other patients. Anyway, the whole experience of working as a paramedic prior to studying in Australia was an eye opener to purse the roots of higher training so as to enhance my professional performance as a paramedic.

Int 003: I have worked as a paramedic for 4½yrs

Interviewer: Do you have any speciality?

Int 003: Not really, just been involved in general paramedical practice.

Interviewer: What was the most positive aspect of working as a paramedic in Saudi Arabia?

Int 003: Despite the many challenges, the most important aspect of the whole experience revolves around the fact that our paramedic services saved hundreds of lives. Working in Saudi Arabia was also a great source of inspiration seeing people appreciating our work and encouraging us to continue helping the society in providing healthcare emergency response.

Interviewer: What do you see as the main causes of stress for Saudi paramedics?

Int 003: The main causes of stress included overwhelming workload due to understaffing. On the other hand, the society has become excessively concerned with the issues of patients rights and ethical practice. Any slight mistake would be blown out of proportion in trying to qualify it as a matter of professional negligence or malpractice. While this remained the biggest cause of stress, withdrawing one’s services was not an option especially when bound by the moral obligation to save life, alleviate suffering and promote good health.

Interviewer: How do these stressors effect the operation (efficiency) of paramedics? What effect do they have on your morale and sick leave days?

Int 003: Owing to the fact that we work longer hours almost 7days a week, most of us often develop fatigue and burnout. This reduces our productivity and sometimes sick leaves are inevitable when one of us is worn down by fatigue and burnout. Typically, the sick leaves may last for even one week or two depending on the magnitude of psychological breakdown.

Threats of malpractice claims also demoralize some paramedics. Personally, this has often discouraged me from taking initiative to help a patient while off duty because of no proper legal protection accorded to use out of the ordinary course of duty. If anything goes wrong, I would be held personally liable. Furthermore, we find it necessary to make the best of our free time to socialize with family and friends and jut avoid anything to do with normal paramedics duties because this in the only time we have to rest and relieve a whole week’s work related stress.

Interviewer: What could the administration or management at the various Emergency Centers do to lower the levels of