Administration and Leadership, International

Optimizing Workplace Support to Manage Stress and Improve Health

Issue 1 and Volume 42.

The incidents that face EMS personal are varied and unpredictable; there are a variety of pressures placed upon clinicians and crucial decisions need to be made in a timely fashion.1,2 This, coupled with managerial pressure to perform clinically, longer working hours and a demanding general public watching on, can mean every 9-1-1 call has the potential to be stressful.2–5 There are measures that can help control the stress, but with such a variety of stressors both organizational and operational, these measures are limited.6

JEMS international article

“Stress” can be defined as a behavioral, psychological or physiological response to a perceived imbalance between what the clinician believes their ability is and what they believe is required from them to deal with a particular situation.1,2

Work-related stress has the real potential to produce long-term mental health problems.7 Additionally, the risk of stroke, myocardial infarction and depression are significantly increased.8–10 Stress can have a negative effect on family relationships and the employee’s general quality of life, often resulting in long-term sickness absence.3,11 In turn, the rest of the staff are required to manage the increased workload due to uncovered shifts, while still meeting response times, adhering to clinical performance indicators and providing high-quality care to the patient.12,13

EMS guidance for managers
There’s often a lack of guidance for managers who are
requested to speak to staff after a traumatic incident,
despite there being published national guidelines.

Organizational Support

In the U.K., where EMS and ambulance transport is provided to people with acute illness or injury via 14 agencies, each ambulance trust would espouse the fact that they’re dedicated to ensuring that the staff is fully supported when it comes to dealing with work-related stress, with the health and well-being of their staff at the top of the list of priorities.14 However, it’s been shown that a number of frontline staff members believe management never show concern for employee welfare, describing them as insensitive and un-empathetic.15 Staff members don’t feel like they can turn to a manager if they need support—they prefer peer-to-peer support.16

Support provided by management is sporadic and, on occasion, still incorporates the use of the single debrief session. This method has little or no evidence supporting its use.17 Furthermore, the practice can actually further embed negative feelings and lead to resentment.18 Additionally, there are a number of complexities that impact the way different clinicians react to different incidents; the single-session debrief method doesn’t take these variables into account.19

Instead, the clinician should be offered practical support: information about how to cope throughout the weeks following the incident and a follow-up component conducted after the initial incident.20,21

Evidence suggests this alternative support mechanism should be required and easily accessible, and not provided by an individual who’s responsible for the day-to-day management of employees.22

Coping Methods

Coping methods aim to create an emotional distance between the clinician and the incident, allowing them to maintain their mental health.3 Some methods are documented as being successful in achieving the desired effect, while others are clearly dangerous putting the individual at greater risk of harm.16

Research suggests that clinicians employ a synthesis of coping methods to help them to process and manage stress, allowing them to return to a normative emotional state.15,23 However, there’s only a small amount of research that looks specifically at the informal coping mechanisms employed by prehospital clinicians. The combined use of humor, support from family, friends and peers, and professional reflection are all used as coping mechanisms.16

EMS support for workplace stress
The combined use of humor, support from family,
friends and peers, and professional reflection are
all used as coping mechanisms after a tough call.

However, risky behaviors such as relying on alcohol or other substances are sometimes used to deal with difficult feelings.16 The use of alcohol as a short-term coping mechanism was found to be popular with as many as 50% of participants of a study, despite the users’ acknowledgement that it wasn’t helpful.24 Alcohol use became problematic for some staff and was often linked to burnout.25

There are many complexities to how staff react and consequently cope with stress, and some don’t suffer any adverse effects when dealing with a traumatic incident.2,3 Factors such as age, sex, length of service, family patterns, previous education and previous exposure to stressful incidents all play an intricate part in how one reacts to stress. 26

This poses a challenge in trying to ascertain which members of staff are more likely to be at risk from becoming unwell due to an inability to manage stress. It could be argued that identifying an at-risk individual may in itself be a stressor. All staff should be deemed to be at risk of stress-related illness and be offered the same level of assessment and support.

Peer-to-Peer Screening

Individuals are often concerned that there will be social or occupational implications to a revelation that they have a problem.3 For example, all U.K. ambulance trust employees have access to professional counseling, but this usually requires a referral, which is seldom done due to the stigma of seeking help and is often too late as symptoms are already present.3,27 There needs to be certain sensitivity with any form of staff support in order to address problems that may be socially frowned upon, especially considering the culture within the ambulance service where there’s an expectation that one will have a robust form of resilience toward stress.11,16

The trauma risk management (TRiM) system, which originated in the U.K. military and has been developed over the past decade, is a peer-to-peer screening tool that can identify stress in providers. The assessment is delivered by operational personnel who’ve been trained in psychological risk assessment and have been furnished with a basic understanding of trauma psychology. This basic training isn’t intended to provide the skills to deliver counseling; instead it enables an individual to refer the employee for professional counselling when it’s needed. The peer assessor can also recommend something as simple as a change in working pattern for a period of time.21

The delivery by peers allows robust accessibility and is well-accepted by clinicians.22 The TRiM assessors are also equipped to deliver support and information to the individual’s family.

There’s often a lack of guidance for managers who are requested to speak to staff after a traumatic incident, despite there being published national guidelines in the U.K. After a traumatic incident, TRiM assessors offer a structured risk assessment for the individual who has been exposed to such an event. This allows the organization to follow best practice guidelines. The second TRiM assessment is carried out approximately one month after the incident, therefore reducing the stigma of seeking help by providing peer support.28,29

The expected benefits are to provide information about what to expect when experiencing a traumatic incident. The stigma that exists around seeking help for mental health problems can then also be addressed.3 By providing this support, the organization will be demonstrating a concern for the health and wellbeing of their employees, as well as adhering to their legal and ethical obligations.14 Additionally, the feeling of an abundance or lack of support directly affects the quality of care delivered to the patient.3,30


The key to a successful outcome is early identification of stress.18 The TRiM support method’s intention isn’t to provide treatment—it’s to provide support, information and referral to occupational health for professional counseling if necessary. This in turn will ensure a healthy workforce, enabling staff members to continue to provide the highest care possible to their patient. The feeling of being supported by the organization can also have a positive effect on staff morale.

Because TRiM is peer-led, post-incident asessments are carefully planned, and there’s a follow-up component designed to detect stress symptoms. It can therefore provide organizations with a simple tool to promote resilience and good mental health, and avoid unnecessary involvement from management.


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