Prevalence of PTSD in Australian Ambulance Personnel - Research Proposal Example

Date Full Title Prevalence of post-traumatic stress disorder (PTSD) in Australian ambulance personnel: Measuring daily stress level of the ambulance workers. Brief Title Prevalence of post-traumatic stress disorder (PTSD) in Australian ambulance personnel Submitted By Please complete the Research Application Form PROPOSAL INFORMATION 1. Full project title 2. a. Type of research project  Randomised controlled trial  Clinical trial  Prospective cohort (or case review)  Retrospective cohort (or case review)  Case control project  Case cross over project  Cross sectional project  Other: __Sample survey __________________________________________ b. Is the project a pilot project for a larger project?  Yes  No If Yes, please provide a brief description of the larger intended project 3. Outline the literature supporting the research project and the aim of this project within this ambulance service (minimum 600 words) Various past studies have addressed the issue of post-traumatic stress disorder (PTSD) found in personnel working with the ambulance services. One such major study was being conducted in Sweden wherein 362 subjects were studied to understand whether ambulance workers suffered from PTSD or not. As per the study, ambulance workers showed PTSD symptoms of around 12 per cent on the Post-traumatic Symptom Scale (PTSS-10), while on the Impact of Event Scale (IES) the same was around 15 per cent to 21.5 per cent, depending on the criteria. The authors therefore stated that the occurrence of PTSD symptoms in ambulance personnel were much higher as compared to the general people of Sweden (Jonsson & Segesten 2004). Another study in the US found that ambulance workers with PTSD symptoms were around 20 per cent, as measured through the Minnesota Multiphasic Personnelity Inventory-2 PTSD Scale. As compared to general populace, this figure was quite high, as only 10 per cent of general women and 5 per cent of the general men suffered from PTSD (Grevin 1996). However, both the studies did not take into account t-values or confidence intervals which could have helped to make the comparisons authentic. Several other studies in this field were also conducted that measured the prevalence rate of PTSD through IES in countries such as Scotland (Alexander & Klein 2001) and Canada (Regehr et al 2002). Another study was conducted in the UK that applied the Post-traumatic Diagnostic Scale (Bennett et al 2004). A study by Regehr et al (2002) found a little lower prevalence of PTSD, about 15.9 per cent in Canada and another one in Netherlands found only 12 per cent prevalence (van der Ploeg & Kleber 2003). In another study by Mahony (2001), qualitative methods were applied to find out stress related to work among ambulance personnel in Australia. It was found that the very nature of the service and the way the ambulance personnel are treated creates stress in their work. Further, other occupation related stress factors such as working in night shifts and erratic work schedule also aggravate the situation. However, the greatest stress inducer is witnessing trauma, death and tragedy. Although, all these situations have become a part and parcel of an ambulance worker’s life and are considered to be a part of their work profile, it is actually viewed as organisational stress factors, which if left unsolved may cause serious mental illness as well. Therefore, a review of previous studies have indicated that the occurrence of PTSD symptoms have been found high in ambulance service personnel. On an average, it has been seen that around 20 per cent of the ambulance personnels indicate PTSD symptoms. However, these studies have not found out whether the occurrence of PTSD is higher in ambulance workers or any other occupation as well. None of the study conducted any comparative research between the prevalence of PTSD symptoms in ambulance workers and other workers in different divisions or occupation. Further, these studies indicated that in most cases the ambulance personnel become vulnerable towards PTSD after helping out victims of a traumatic event. These studies did not mention whether the daily job responsibilities of the ambulance personnel have also contributed towards creating trauma and stress in these workers. Most of the literature reviewed focused on the occurrence of trauma after a disaster, but only a study by Jonsson & Segesten (2004) highlighted on the impact of day-to-day work on the stress level of ambulance workers. This study indicated that around 12 to 15 per cent ambulance workers are prone to PTSD due to their daily work. However, no such study could be found in the Australian context. Therefore, I have decided to conduct my study in this field to understand whether the daily stress level felt by the ambulance personnel in Australia while conducting their day-to-day job also contributes towards PTSD or not. 4. Provide a description of how the research may benefit this Ambulance Service (dot points OK) The occurrence of PTSD symptoms in personnel with ambulance services indicates that these workers are not able to cope up with the stress level they encounter while doing their daily work. This study would be very useful to find out the stress level and predicting the level of vulnerability for PTSD in ambulance personnel who are recent hires. Subsequently, the hospital administration may take preventive steps to protect the employees against the mental stress that may occur from their occupation. In order to reduce or prevent the occurrence of PTSD symptoms in ambulance workers, the administration may decide to provide leaves to the affected employees, depending on their conditions, so that their conditions are not aggravated and impact their work. Further, in case of employees with higher stress level, the administration may decide to transfer them to divisions with lesser emergency duties. The study would aim to understand the relation between PTSD symptoms and the factors that result to these symptoms in ambulance personnel. This would help in negating the factors that result in PTSD symptoms in ambulance workers in the future. Further, the study would help in developing strategies for workers with emergency services on how to prevent and treat mental health issues that arises due to the nature of the work. However, in order to formulate such strategies, it is needed to understand the magnitude and severity of the issue, which this study would also take into account. The research would also critically analyse the current practices that are being used to help ambulance workers to cope with work related stress. Such an analysis would help in understanding whether the current practices are practical or not and whether they have any real benefits as well. For instance, it has been found that giving brief regarding critical incident, which is being used as a preventive treatment, instead of helping the ambulance workers impact them negatively (Grevin 1996). Thus, it is needed to question the old and established practices and look at newer approaches to solve the issue and identify various other factors related to the disorder. The study would also focus on various preventive strategies that the hospital administration may apply to prevent the occurrence of PTSD in emergency services staff. 5. Outline description of the study methods (minimum 500 words) In order to conduct this study, a sample survey would be conducted amongst the ambulance staff of Victorian Ambulance Service. The sample would consist of paramedics as well as emergency medical technicians (EMTs), who have at least been able to handle or witnessed one critical and traumatic event. In order to keep the names of the survey respondents anonymous, the questionnaire would not have any indicators such as name or employee ID number that would identify the employee. The questionnaire would include items that would measure the responses of the employees in terms of yes or no as per their past experience in their job. Further, the participants would also be asked to undertake the Posttraumatic Diagnostic Scale (PDS), which would then be analysed against the psychiatric ratings (Foa et al 1997). The analysis of the score would establish whether the employee is suffering from PTSD or not. The participants would also be asked to undertake the Hospital Anxiety and Depression Scale (HADS). This would consist of a total of 14 items, each one with a severity score of four points. In case an employee scores 11 or more, the analysis would indicate that the worker might be suffering from depression and anxiety (Zigmond & Snaith 1983). The questioner would focus on issues such as being absent from work due to mental stress, need for social support, causes of distress as well as understanding the personality of the employee. The questioner would also help in providing comparative data between various groups, especially those who have taken leave due to stress and those who have not. Further, logistic regression would be implemented to understand the reasons for taking the leaves. The questioner also addressed issues such as demographics like gender, age, education and experience in ambulance and emergency services etc. Also, the questioner helped in understanding whether the employees were given briefing regarding critical incidents and whether the number of leaves increased after a critical event. This study would also conduct inquiry to find out whether the respondents are suffering from posttraumatic stress and depression. In order to analyse this, Beck Depression Inventory (BDI) would be conducted to assess whether the employee is suffering from any cognitive disorder or depression (Beck 1974). Further, in order to assess the personality of the employees, the Bell Object Relations and Reality Testing Inventory (BORRTI) would be used. This particular instrument would help in understanding the personality patterns of the emergency services employees (Bell et al 1985). In case of increase in the alienation subscale it would mean that the employee is suffering from isolation, a hostile behaviour, suspiciousness and absence of trust. Further, such increase in the subscale would also mean that the employee is sensitive towards being rejected or any type of loss. He or she may have guilt feelings, become jealous and have anxiety while in a relationship. In case the employee scores high on egocentricity subscale, the person may mistrust the motivations of others and may have tendencies to be demanding. Further, in order to understand whether the person is getting enough support from his or her family, friends, peers, other employees and the management, the respondents would be asked to rate the level of support they get from others on the scale of 0 to 5, where 5 would mean very supportive. 6. Outline of proposed project timing a. Duration (months): 2 months b. Anticipated commencement date: September 1, 2010 c. Anticipated completion date: November 1, 2010 d. Please complete the proposed timeline for project activities including all project activities: Activity (eg interviews) Start date Duration (eg 4 weeks) With emergency medical technicians (EMTs) September 13, 2010 September 24, 2010 With paramedics September 27, 2010 October 8, 2010 7. Project summary Does the project involve:  Participants  Paramedics  Patients  Other Ambulance Service staff  Collection, use or disclosure of Ambulance Service information  Drug or device trial 8. What Ambulance Service Policies are affected by this project and how? The study aims to question the current practices in the ambulance services in order to find out whether these practices are relevant in today’s context or not. As the policies are also formulated as per the prevailing practices, in case of any new findings in the study the policies governing the ambulance service would also need to be modified. For instance, in case of a number of employees showing depression or stress, it might be stated that the hospital’s policies are not as per the requirements of the employees and the hospital need to revisit them. The employees might require more leaves and strong support system to undertake such strenuous work. Thus, the policy changes would depend on the results from the study. 9. Data collection Does the data collection for the project involve:  Survey(s)  Retrieval of Ambulance Service Patient Care Records  Retrieval of 000 call data (tapes)  Access to Ambulance Service registry (electronic) data  Interviews / focus groups  Additional collection of project specific data (e.g. a study form to be completed by paramedics and / or patients and attached to PCR)  Other data collection methods (specify):___________ 10. Provide details of data collection. How many records will be collected and/or participants will be involved? Specify the information that will be collected, used or disclosed. In order to conduct the study, the ambulance staff of Victorian Ambulance Service would be interviewed for a period of around a month. The study would consist of the paramedics as well as emergency medical technicians (EMTs) in the hospital, who have at least been able to handle or witnessed one critical and traumatic event. The study aims to collect interviews from at least 50 ambulance staff. The study would not only try to understand the stress level in the employees through various questions, but would also collect several important data such as gender, age, education and experience in ambulance and emergency services from the participants. Further, data would also be collected on issues such as being absent from work due to mental stress, need for social support, causes of distress as well as understanding the personality of the employee. The study would only publish the results of the data analysed and the names of the survey respondents would be kept anonymous, as questionnaire would not have any indicators such as name or employee ID number that would identify the employee. 11. Provide a detailed statement of what would be required of Ambulance Service personnel In order to conduct this study, the ambulance service personnel would be approached and asked whether they would be interested in participating for the survey. In case they agree for the study, the participants would be given details about the requirements for participating in the survey. The only thing that would be required out of the participants would be their time for conducting the survey. The researcher would send in the questioner to the participants and ask them to fill them. Later they would be asked to undergo some psychometric tests again through the use of questioners. They may fill them at their leisure or by blocking time with the researcher. The study would require the participants to provide honest opinion about their work and their stress level. They would be assured that the information would not be given to any third party or to the hospital administration. Truthfulness from the respondents is very essential for the success of this study. Paramedic time calculator Paramedic Type Number of hours required Total hours Training Project Ambulance paramedic 80 80 Team Manager MICA CSO 80 80 Group Manager Total 160 12. Provide a statement of likely training requirements for Ambulance Service personnel – what is the training and how and by whom will it be delivered?       This study would not require any training 13. Analysis of likely financial costs for Ambulance Service Provide a proposed draft project budget including: Ambulance Service participant reimbursement  Yes  NA Ambulance Service administration costs  Yes  NA Ambulance Service specific intervention (eg drug) costs  Yes  NA Estimated Potential Cost Amount Requested ($) 14. Source of project funding How will this project be funded? List at least one potential source of funds (e.g. grants, commercial sponsorship, organisational / departmental funds) Potential Source Amount Requested ($) 15. Describe the ethical considerations specific to Ambulance Service (minimum 500 words)       Anticipated Benefits: It is important to carry out ethical consideration before conducting a study involving ambulance service personnel. As the respondents are already going through the trauma of handling their diseases, such surveys and studies might add up to their discomforts. Therefore, outlining ethical considerations even before starting the study would ensure that the respondents are given the maximum security and safety. Further, they would also be assured that the researchers would take every care of their comfort. Risks of any harm: However, it is also important to understand that such studies means creating long lasting relationships with the respondent. Further, the researcher should take care of not causing any physical disturbance, discomfort, anxiety or pain or any potential damage to the reputation of the hospital or the relationship between the respondents and the hospital administration. Options of withdrawal: The participants should be given the option to withdraw from the survey at any point of time. The researcher should not impose compulsion to finish the survey with the participants. In case any participant is not comfortable with the survey or any question, he or she should be given the option to withdraw from the survey on a voluntary basis. The researcher should not make any issue or complaints against the respondent in such cases. Source of payment for normal participants: The study did not require any payment to the participant Protection of privacy and preservation of confidentiality: The researchers were bound to protect the privacy of the participants. All the participants were given a confidentiality agreement which stated that their identity would remain confidential and psuedonyms would be used in place of real names of the patients. Creating an environment of trust: The researcher would make it a priority to create an environment of trust with both the participants and the hospital administration. The researcher assures that the data collected would not be shared with anybody else and would be used solely for the purpose of this study. As the participant would be sharing his or her personal opinion, and some of them might be about the administration as well, the researcher would take care not to share that information with the hospital administration as it might create professional problems for the respondent. Similarly, the hospital administration may share some vital information regarding the respondents, which the researcher would solely use for background for the study and would not share with the respondents. The researcher would take care not to create discord between the respondents and the management. Restriction of use of data: Further, it would also confirm that the data would only be used for the purpose of this particular research and would not be sold to any third party. The researcher would assure both the respondents and the hospital administration that the data would be only used for this particular study and would not be shared with any other researcher or organisation. Any other ethical considerations: The researcher would take special care of people who report particular religious or cultural sentiments that require them to perform in a certain manner. 16. List Ethics Committee(s) that will need to review the protocol       17. List the potential risks of the project and how these would be mitigated       The major risks of the project are as listed below: Conflict between the employees and the management: The employees and the management should not be in conflict with each other due to this study. The employees should not be made to feel that the management is not taking care of them properly. Further, the management should not believe that the employees are talking ill for them. The mental health consideration: The participants should not be stressed about the survey and they should be willingly answer the questions and participate in the tests. Any stressful question might increase their depression level and would cause harm to their health. Disturbing the work: The survey should be conducted in such a manner that it should not disrupt the schedule of the respondents. Instead, the researcher should carry out the survey in such a manner that it should accommodate the preferred timings of the respondents. 18. List at least three journals and/or conferences which would be suitable for the publication of project results       Emerg Med J Occup Environ Med Psychol Assess 19. References Alexander DA, Klein S. Ambulance personnel and critical incidents: impact of accident and emergency work on mental health and emotional well-being. Br J Psychiatry 2001, 178:76-81. Beck A, Beamesderfer A. Assessment of depression: the depression inventory. In: Pichot P, editor. Psychological measurements in psychopharmacology. Volume 7. Paris: Karger, Basel; 1974. p 151–69. Bell M, Billington R, Becker B. Scale for the assessment of reality testing: reliability, validity and factorial invariance. J Consult Clin Psychol 1985;53:506–11. Bennett P, Williams Y, Page N, Hood K, Woollard M: Levels of mental health problems among UK emergency ambulance workers. Emerg Med J 2004, 21:235-236. Foa EB, Cashman L, Jaycox L, et al. The validation of a self-report measure of posttraumatic stress disorder: the Posttraumatic Diagnostic Scale. Psychol Assess 1997;9:445–51. Grevin F: Posttraumatic stress disorder, ego defense mechanisms, and empathy among urban paramedics. Psychol Rep 1996, 79:483-495. Jonsson A, Segesten K: Daily stress and concept of self in Swedish ambulance personnel. Prehospital Disaster Med 2004, 19:226-234. Regehr C, Goldberg G, Hughes J: Exposure to human tragedy, empathy, and trauma in ambulance paramedics. Am J Orthopsychiatry 2002, 72:505-513. Regehr C, Hill J, Goldberg G, Hughes J: Postmortem inquiries and trauma responses in paramedics and firefighters. J Interpers Violence 2003, 18:607-622. van der Ploeg E, Kleber RJ: Acute and chronic job stressors among ambulance personnel: predictors of health symptoms. Occup Environ Med 2003, 60(Suppl 1):i40-46. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361–70. Read More