Shame and Guilt in EMS: A Qualitative Analysis of Culture and Attitudes in Prehospital Emergency Care.

STUDY OBJECTIVES: The shame reaction is a highly negative emotional reaction shown to have long-term deleterious effects on the mental health of clinicians. Prior studies have focused on in-hospital personnel, but very little is known about what drives shame reactions in emergency medical services (EMS), a field with very high rates of post-traumatic stress disorder, burnout, anxiety, and depression. The objective of this study was to describe emotions, processes, and resilience associated with self-identified adverse events in the work of prehospital clinicians. METHODS: We conducted a qualitative study using a modified critical incident technique. Participants were recruited from two EMS agencies in North Carolina: one urban and one rural. They provided an open-ended, written reflection in which they were asked to self-identify particular events in their EMS careers that felt emotionally difficult. In-person or video in-depth interviews about these events were then conducted in a semi-structured fashion using an iterative interview guide. The codebook was developed through a mix of inductive and deductive analysis strategies and discussed within the research team and a content expert for validation. Interviews were transcribed and data were analyzed following a thematic content analysis approach for types of cases identified as emotionally difficult, common emotional responses and coping mechanisms, and the lingering effects of these experiences on study subjects. RESULTS: Eight interviews were conducted with EMS personnel: five from an urban agency and three from a rural agency. Participants commonly identified complex medical cases as being emotionally difficult, which led to the most robust shame reactions. Shame reactions were more common when EMS clinicians committed self-perceived errors in patient care, whereas guilt reactions were more common when patient outcomes seemed "inevitable" despite any intervention. Common themes related to coping mechanisms included both personal mechanisms, which tended to be less successful compared to interpersonal mechanisms, particularly when emotions were shared with colleagues. This reflected a perceived culture change within EMS in which sharing emotions with colleagues was seen as a departure from the "old school" where emotions tended to be kept to oneself. Feelings of inadequacy, low self-worth, and being "not good enough" were frequently identified as lingering emotions after difficult cases that were hard to move on from, corresponding to longstanding shame in these clinicians. Recovery and resilience varied but tended to be positively associated with a culture in which sharing with colleagues was encouraged, along with personal introspection on root causes for the sentinel event. CONCLUSION: EMS clinicians often identify complex patient cases as those leading to emotions such as shame and guilt, with shame reactions being more common when a perceived error was committed. Coping mechanisms were varied, but individuals often relied on their coworkers in a sharing environment to adequately process their negative feelings, which was seen as a departure from past practices in EMS personnel. Our hope is that future studies will be able to use these findings to identify targets for intervention on negative mental health outcomes in EMS personnel.

Diversity, Equity, and Inclusion in the United States Emergency Medical Services Workforce: A Scoping Review.

OBJECTIVE: Emergency medical services (EMS) workforce demographics in the United States do not reflect the diversity of the population served. Despite some efforts by professional organizations to create a more representative workforce, little has changed in the last decade. This scoping review aims to summarize existing literature on the demographic composition, recruitment, retention, and workplace experience of underrepresented groups within EMS. METHODS: Peer-reviewed studies were obtained from a search of PubMed, CINAHL, Web of Science, ProQuest Thesis and Dissertations, and non-peer-reviewed ("gray") literature from 1960 to present. Abstracts and included full-text articles were screened by two independent reviewers trained on inclusion/exclusion criteria. Studies were included if they pertained to the demographics, training, hiring, retention, promotion, compensation, or workplace experience of underrepresented groups in United States EMS by race, ethnicity, sexual orientation, or gender. Studies of non-EMS fire department activities were excluded. Disputes were resolved by two authors. A single reviewer screened the gray literature. Data extraction was performed using a standardized electronic form. Results were summarized qualitatively. RESULTS: We identified 87 relevant full-text articles from the peer-reviewed literature and 250 items of gray literature. Primary themes emerging from peer-reviewed literature included workplace experience (n = 48), demographics (n = 12), workforce entry and exit (n = 8), education and testing (n = 7), compensation and benefits (n = 5), and leadership, mentorship, and promotion (n = 4). Most articles focused on sex/gender comparisons (65/87, 75%), followed by race/ethnicity comparisons (42/87, 48%). Few articles examined sexual orientation (3/87, 3%). One study focused on telecommunicators and three included EMS physicians. Most studies (n = 60, 69%) were published in the last decade. In the gray literature, media articles (216/250, 86%) demonstrated significant industry discourse surrounding these primary themes. CONCLUSIONS: Existing EMS workforce research demonstrates continued underrepresentation of women and nonwhite personnel. Additionally, these studies raise concerns for pervasive negative workplace experiences including sexual harassment and factors that negatively affect recruitment and retention, including bias in candidate testing, a gender pay gap, and unequal promotion opportunities. Additional research is needed to elucidate recruitment and retention program efficacy, the demographic composition of EMS leadership, and the prevalence of racial harassment and discrimination in this workforce.

Presence of undertriage and overtriage in simple triage and rapid treatment.

OBJECTIVE: We evaluated the use of the Simple Triage and Rapid Treatment (START) method by Emergency Medical Services (EMS) and hypothesized that EMS can categorize patients using the START algorithm accurately. DESIGN: Retrospective Chart Review. SETTING: Inner-city Tertiary-Care Institutional Emergency Department (ED). PARTICIPANTS: Patients ≥ 18 years transported by EMS with a START color of Red, Yellow, or Green during the state triage tag exercise, October 9-15, 2011. INTERVENTIONS: EMS assigned each patient a START triage tag. Chart review of the electronic EMS run sheets was performed by investigators to determine a START color. MAIN OUTCOME MEASURES: START triage colors were re-categorized as Red = 1, Yellow = 2, and Green = 3. The difference between the investigators' color and EMS color were coded as: 0 for agreement in triage, -1 for undertriage by one category, -2 for undertriage by two categories, 1 for overtriage by one category, 2 for overtriage by two categories. RESULTS: Of 224 participants, START triage colors were: Red = 7.1 percent, Yellow = 19.2 percent, Green = 73.7 percent. The mean difference in triage categories was 0.228 (95% CI: 0.114-0.311, p<.001). 71.0 percent of patients were triaged to the same category, 5.8 percent undertriaged by one category, 0 percent undertriaged by two categories, 17.9 percent overtriaged by one category, and 5.4 percent overtriaged by two categories. CONCLUSION: EMS was more likely to overtriage using START. All patients who were overtriaged by two categories were ambulatory at the scene, which implies other findings not in START may affect triage.