An Assessment of Burnout Among Emergency Medical Services Professionals

An Assessment of Burnout among Emergency Medical Services Professionals

DISSERTATION

Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University

Remle Patricia Crowe

Graduate Program in Public Health

The Ohio State University

2018

Dissertation Committee

Amy Ferketich, Advisor

Sarah Anderson

Rebecca Andridge

Tory Hogan

Ashish Panchal

Copyrighted by

Remle Patricia Crowe

2018

Abstract

Background: Emergency medical services (EMS) professionals routinely face high demands, physically, mentally, and emotionally. Due to the intense demands characteristic of providing prehospital care, EMS professionals may be at increased risk for occupational burnout. Burnout is a condition characterized by extreme emotional and physical exhaustion that has been associated with negative effects for employees and their workplaces. The overarching goal of this project was to inform the development of interventions to reduce the negative impact of burnout and improve the well-being of

EMS professionals. The objectives were three-fold: 1) quantify burnout at the EMS agency level and identify associated agency characteristics, 2) identify specific job characteristics associated with burnout, and 3) quantify the link between burnout, turnover, sickness absence, and occupational injury.

Methods: To answer Aims 1 and 2, an electronic questionnaire was designed to assess burnout and job characteristics. The questionnaire was deployed to all licensed, practicing EMS professionals in the state of South Carolina. Agency rosters maintained through the state credentialing information system were used to aggregate data. For Aim

3, an observational cohort study was conducted at a large, county-based EMS agency in

North Carolina. Burnout was measured at baseline using an electronic questionnaire.

Turnover, sickness absence, and occupational injuries were assessed prospectively using

ii records maintained by the EMS agency. In both studies, burnout was measured using the work-related and patient-related subscales of the Copenhagen Burnout Inventory.

Results: The statewide cross-sectional assessment revealed variation in the prevalence of burnout across EMS agencies. Further, annual call volume and the number of EMS employees were agency characteristics associated with the prevalence of both work- related and patient-related burnout. Important job demands associated with both burnout domains included time pressure, posting in an emergency vehicle, and components of the base environment (e.g., having a place to eat/prepare food). Important job resources associated with work-related and patient-related burnout included performance feedback, paid uniforms, tuition assistance, job control, a participatory work environment, respect from supervisors, and adequate training. High job demands and low job resources were associated with a dramatic increase in odds of burnout. The relationship between high job demands and increased odds of burnout as attenuated by high job resources. Meanwhile, the prospective cohort study findings suggested a link between burnout and increased turnover and sickness absence, though statistical significance was not reached. No significant relationship was identified between burnout and occupational injury in this study.

Conclusions: Increased burnout may negatively impact EMS professionals and agencies through increased sickness absence and turnover. Variation in burnout between agencies and the strong link between burnout and job characteristics suggest that burnout can be affected at the level of the EMS agency. Increasing job resources may have a positive impact on agencies, especially when job demands are high and not easily modified.

Dedication

I dedicate this work to my grandmothers, Remle and Patricia.

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Acknowledgements

First, and foremost, I would like to express my deep gratitude to my advisor, Dr.

Amy Ferketich. Thank you for your relentless mentorship, support, and patience. I am grateful for the discipline you helped me develop in setting objectives and meeting them.

Most of all, thank you for being such a kind and caring person and always helping others.

Your example inspires and motivates me to do more and be better.

I am also thankful for the guidance from my committee members. I thank Dr.

Anderson for her expertise in survey methodology and thoughtful comments throughout the writing process. I am grateful to Dr. Andridge for her guidance in the data analysis. I am appreciative of Dr. Hogan’s guidance on theoretical frameworks and organizational research. I am also thankful for Dr. Panchal’s clinical expertise and guidance regarding the implications of our findings.

I would like to thank the National Registry of EMTs for answering the call to help train a cadre of trained EMS researchers and for the opportunity to be part of the EMS

Research Fellowship. I would especially like to thank my Research Department family.

Ash, ‘thank U’ for your leadership and mentorship. Rebecca, thank you for always lending and ear, or a brain cell (or several billion). Madison, thank you for your refreshing positive attitude at all times. I am extremely grateful to Melissa Weant who encouraged me to join the fellowship program and for her patient guidance as I began this journey. I am also thankful for the brothers I inherited from the fellowship program, Tony and Jon. Of course, I appreciate your all-gif message exchanges, but I am deeply grateful for how you generously offered your assistance and provided me with unique opportunities to conduct meaningful research.

I thank the South Carolina Department of Health and Environmental Control’s

Bureau of EMS. I am especially grateful to Rob Wronski for all his work to encourage participation and for his complete support at every stage.

I would also like to thank Mecklenburg EMS Agency (Medic) for their dedication to EMS research and for allowing me the opportunity to conduct a prospective investigation. I am especially grateful to Patricia Dowbiggin for her help with data collection and her positive attitude in the face of my endless requests.

Thank you, Mom and Dad for your never-ending encouragement and enthusiasm.

Thank you to my brothers, Tim and Jon. I thank my cousin Jill for always being a great example of what hard work can bring. Thank you, Trisha and Teresa for being my second family when I’m home and away. I thank Lesley for always cheering me on. Thank you,

Elizabeth for the phone calls and visits along the way. I love and appreciate all of my

Ohana. Your support keeps me going for more.

I would also like to express my gratitude to my EMS family. Scott, I appreciate all your support at conferences, edits to papers, abstracts, and posters, and most importantly, for preventing the hanger. Thank you, José for your support and collaboration. Jeff, thank you for always stretching my brain with research questions and for making nerdy cool. Dee Dee, thank you for always sticking by my side.

Finally, I thank my Columbus family. Thank you, Sara for your friendship at school and for always being willing to set the table for one more at home. I thank Chris for bringing me coffee AND tacos at the same time on long days. Thank you, Corinne and Beth for the girls’ night escapes and celebrations after exams and program milestones.

Vita

2006...... William G. Enloe High School

2010...... B.S. Business, Language, and Culture,

The American University

2011...... Emergency Medical Technician,

Mexican Red Cross

2013 to present ...... EMS Research Fellow,

The National Registry of EMTs

2016...... M.S. Public Health, Epidemiology,

The Ohio State University

Publications

Panchal AR, Cash RE, Crowe RP, Coute R, Way D, Aufderheide T, Merchant R (2018).

Delphi Analysis of Science Gaps in the 2015 American Heart Association Cardiac

Arrest Guidelines. Journal of the American Heart Association; Forthcoming.

Crowe RP, Cash RE, Christgen A, Hilmas T, Varner L, Vogelsmeier A, Gilmore WS,

Panchal AR (2018). Psychometric Analysis of a Survey on Patient Safety Culture

(SOPS)-Based Tool for Emergency Medical Services. Journal of Patient Safety;

Forthcoming.

Fishe JN, Crowe RP, Cash RE, Nudell NG, Martin-Gill C, Richards CT (2018).

Implementing Prehospital Evidence-Based Guidelines: A Systematic Literature

Review. Prehospital Emergency Care; Forthcoming.

Rodriguez SA, Crowe RP, Cash RE, Broussard A, Panchal AR (2017). Graduates from

Accredited Paramedic Programs Have Higher Pass Rates on a National

Certification Examination. Journal of Allied Health; Forthcoming.

Crowe RP, Bower JK, Cash RE, Panchal AR, Rodriguez SA, Olivo-Marston, SE (2018).

Association of Burnout with Workforce-Reducing Factors among EMS

Professionals. Prehospital Emergency Care; 22(2): 229-236.

Buckland D, Crowe RP, Cash RE, Gondek S, Maluso P, Sirajuddin S, Dangerfield P,

Shapiro G, Wanka C, Panchal AR, Sarani B (2018). Ketamine in the Prehospital

Environment: A National Survey of Paramedics in the United States. Prehospital

and Disaster Medicine; 33(1): 23-38.

Cash RE, Crowe RP, Agarwal R, Rodriguez SA, Panchal AR (2018). Exiting the

Emergency Medical Services Profession and Characteristics Associated with

Intent to Return to Practice. Prehospital Emergency Care; 22(1): 28-33.

Cash RE, Crowe RP, Rodriguez SA, Panchal AR (2017). Disparities in Feedback

Provision to Emergency Medical Services Professionals. Prehospital Emergency

Care; 21(6): 773-781.

Crowe RP, Bentley MA, Wagoner RL, Rodriguez SA, Page D (2017). Defining

Components of Teamwork in Prehospital Emergency Medical Services.

Prehospital Emergency Care; 21(5): 645-651.

Harper S, Crowe RP, Bentley MA, Kharod C, Walrath B (2017). An Assessment of

National EMT Certification among Enlisted Military Medics. Military Medicine;

182: 336-339.

vii

Hoyle Jr JD, Crowe RP, Bentley MA, Beltran G, Fales W (2017). Pediatric Prehospital

Medication Dosing Errors: A National Survey of Paramedics. Prehospital

Emergency Care; 21(2): 185-191.

Crowe RP, Levine R, Rodriguez S, Larrimore AD, Pirrallo, RG (2016). Public

Perception of Emergency Medical Services in the United States. Prehospital and

Disaster Medicine; 31(S1), S112-S117.

Chapman SA, Crowe RP, Bentley MA (2016). Recruitment and Retention of New

Emergency Medical Technician (EMT)-Basics and Paramedics. Prehospital and

Disaster Medicine; 31(S1), S70-S86.

Crowe RP, Levine R, Eggerichs JJ, Bentley MA (2016). A Longitudinal Description of

Emergency Medical Services Professionals by Race/Ethnicity. Prehospital and

Disaster Medicine; 31(S1), S30-S69.

Chang CD, Crowe RP, Bentley MA, Janezic AR, Leonard JC (2016). EMS Providers'

Beliefs Regarding Spinal Precautions for Pediatric Trauma Transport. Prehospital

Emergency Care; 1-10.

Gormley, MA, Crowe RP, Bentley MA, Levine R (2016). A National Description of

Violence toward Emergency Medical Services Personnel. Prehospital Emergency

Care; 20(4), 439-447.

Crowe RP, Levine R, Bentley MA (2015). Prehospital Helicopter Air Ambulances Part

1: Access, Protocols, and Utilization. Air Medical Journal;34(6):333-336.

Crowe RP, Levine R, Bentley MA (2015). Prehospital Helicopter Air Ambulances Part

2: Utilization Criteria and Training. Air Medical Journal;34(6):337-342.

viii

Liang SY, Vantassell P, Crowe RP, Froelke BR, Marschall J, Bentley MA. Knowledge,

Attitudes, and Practices Regarding Infection Prevention among Emergency

Medical Services Providers. American Journal of Emergency Medicine.

2015;33(5):725-727.

Fields of Study

Major Field: Public Health

Table of Contents

Abstract ...... ii

Dedication ...... iii

Acknowledgements ...... iv

Vita ...... vi

Publications ...... vi

Fields of Study ...... ix

Chapter 1. Introduction & Specific Aims ...... 1

1.1 Specific Aims ...... 5

Chapter 2. Background and Significance...... 7

2.1 Emergency Medical Services Professionals and the Prehospital Setting ...... 7

2.2 Work Stress in EMS...... 8

2.3 Occupational Burnout Definition ...... 9

2.4 Measurement of Burnout ...... 11

2.5 Prevalence of Burnout in Healthcare Professions ...... 13

2.6 Negative Effects of Burnout on the Well-Being of Healthcare Professionals ...... 14

2.7 Burnout and Safety and Injury in Healthcare ...... 15

2.8 Burnout among EMS Professionals ...... 17

2.9 Occupational Injury in EMS ...... 19

2.10 Theoretical Framework ...... 20

2.10.1 Job Demands-Resources Model ...... 21

2.10.2 Conservation of Resources Theory ...... 25

2.11 Innovation & Significance ...... 27

Chapter 3. Research Design and Methods ...... 29

3.1 Overview ...... 29

3.2 Specific Aims 1 & 2: Study Setting ...... 29

3.3 Specific Aims 1 & 2: Instrument Development ...... 30

3.4 Specific Aims 1 & 2: Data Collection ...... 32

3.5 Specific Aims 1 & 2: Non-Responder Survey ...... 33

3.6 Specific Aim 1: Analysis...... 34

3.7 Specific Aim 2: Analysis ...... 35

3.8 Specific Aim 3: Study Setting...... 37

3.9 Specific Aim 3: Data Collection ...... 37

3.10 Specific Aim 3: Analysis ...... 38

Chapter 4. Variation in the Agency-Level Prevalence of Burnout and Associated Agency

Characteristics (Aim 1) ...... 40

4.1 Abstract ...... 40

4.2 Introduction ...... 41

4.2.1 Theoretical Framework: Job Demands-Resources Model ...... 44

4.2.2 Current Study ...... 45

4.3 Methods...... 47

4.3.1 Study Design, Population, and Setting ...... 47

4.3.2 Instrument Development ...... 48

4.3.3 Data Collection ...... 48

4.3.4 Non-Responder Survey ...... 50

4.3.5 Measures ...... 50

4.3.6 Data Analysis ...... 55

4.4 Results ...... 57

4.4.1 EMS Professional Characteristics ...... 57

4.4.2 EMS Agency Characteristics ...... 60

4.4.3 Agency-Level Burnout Prevalence ...... 63

4.4.4 Non-responder Survey Results ...... 68

4.5 Discussion ...... 69

4.5.1 Job Demands-Resources Model ...... 72

4.5.2 Limitations ...... 74

4.5.3 Implications and Future Directions ...... 77

4.6 Conclusions ...... 78

Chapter 5. The Association of Job Resources and Job Demands with Burnout among

Emergency Medical Services Professionals (Aim 2) ...... 79

5.1 Abstract ...... 79

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5.2 Introduction ...... 80

5.2.1 Theoretical Framework: Job Demands-Resources Model ...... 84

5.2.2 Current Study ...... 85

5.3 Methods...... 87

5.3.1 Study Design, Population, and Setting ...... 87

5.3.2 Instrument Development ...... 88

5.3.3 Data Collection ...... 95

5.3.4 Non-Responder Survey ...... 96

5.3.5 Measures ...... 96

5.3.6 Data Analysis ...... 100

5.4 Results ...... 106

5.4.1 Prevalence of Job Demands and Job Resources ...... 109

5.4.2 Work-Related Burnout and Confounding Variables...... 112

5.4.3 Work-Related Burnout and Job Demands ...... 113

5.4.4 Work-Related Burnout and Job Resources ...... 116

5.4.5 Patient-Related Burnout and Confounding Variables...... 118

5.4.6 Patient-Related Burnout and Job Demands ...... 119

5.4.7 Patient-Related Burnout and Job Resources ...... 121

5.4.8 The Association of High/Low Job Demands and High/Low Job Resources with

Burnout ...... 123

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5.4.9 Non-Responder Results ...... 124

5.5 Discussion ...... 125

5.5.1 Job Demands-Resources Model ...... 129

5.5.2 Limitations ...... 130

5.5.3 Implications and Future Directions ...... 133

5.6 Conclusions ...... 136

Chapter 6. The Association of Burnout with Turnover, Sickness Absence, and

Occupational Injury among EMS Professionals (Aim 3) ...... 137

6.1 Abstract ...... 137

6.2 Introduction ...... 139

6.2.1 Theoretical Framework: Conservation of Resources Model ...... 141

6.2.2 Current Study ...... 143

6.3 Methods...... 144

6.3.1 Study Design, Population, and Setting ...... 144

6.3.2 Data Collection ...... 145

6.3.3 Measures ...... 147

6.3.4 Analysis...... 153

6.4 Results ...... 156

6.5 Discussion ...... 162

6.5.1 Conservation of Resources Model ...... 164

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6.5.2 Limitations ...... 165

6.5.3 Implications and Future Directions ...... 168

6.6 Conclusions ...... 169

Chapter 7. Discussion ...... 170

7.1 Summary of Findings ...... 171

7.1.1 Aim 1 Findings ...... 171

7.1.2 Aim 2 Findings ...... 172

7.1.3 Aim 3 Findings ...... 172

7.2 Theoretical Framework ...... 173

7.3 Implications...... 175

7.4 Strengths and Limitations ...... 176

7.5 Conclusions ...... 177

References ...... 179

Appendix A. Survey Instrument for Specific Aims 1 & 2 ...... 200

Appendix B. Pre-notification E-mail from Chief of the South Carolina Bureau of EMS for Specific Aims 1 & 2 ...... 211

Appendix C. Pre-notification Flyer for Specific Aims 1 & 2 ...... 212

Appendix D. E-mail Invitation to Complete Questionnaire for Specific Aims 1 & 2 .... 214

Appendix E. E-mail Invitation to Complete Abbreviated Non-Responder Questionnaire for Specific Aims 1 & 2 ...... 215

Appendix F. Survey Instrument for Specific Aim 3 ...... 216

Appendix G. Prenotification Slide for Specific Aim 3 ...... 221

Appendix H. E-mail Invitation to Participate in Electronic Questionnaire for Specific

Aim 3 ...... 222

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List of Tables

Table 1. Items of the Work-Related and Patient-Related Burnout Subscales of the

Copenhagen Burnout Inventory Adapted for EMS ...... 31

Table 2. Characteristics of Cognitive Debrief Participants (N=10) ...... 32

Table 3. Descriptive Characteristics of EMS Providers (N=1,271) ...... 59

Table 4. Descriptive Characteristics of EMS Agencies by Number of Respondents ...... 62

Table 5. Categories of Work and Patient-Related Burnout Prevalence for EMS Agencies with at Least Five Respondents (N=134)...... 66

Table 6. Comparison of Median Prevalence of Work and Patient-Related Burnout by

Agency Characteristics for Agencies with at Least Five Respondents (N=134) ...... 67

Table 7. Comparison of Agency-level Burnout Prevalence by Number of Respondents 68

Table 8. Comparison of Full Survey and Non-Responder Survey Participant

Characteristics ...... 69

Table 9. Sources for Items Related to Job Demands in EMS ...... 93

Table 10. Sources for Items Related to Job Resources in EMS ...... 94

Table 11. Scoring for Job Demands Composite Measure ...... 104

Table 12. Scoring for Job Resources Composite Measure ...... 105

Table 13. Characteristics of EMS Professionals Included in the Analysis Population

(N=1,271) ...... 108

Table 14. Burnout Prevalence among EMS Professionals in South Carolina by Type of

Burnout ...... 109

Table 15. Prevalence of Job Demands among EMS Professionals in South Carolina ... 111

Table 16. Prevalence of Job Resources among EMS Professionals in South Carolina .. 112

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Table 17. Odds Ratios for the Association between Confounding Variables and Work-

Related Burnout ...... 113

Table 18. Unadjusted and Adjusted Odds Ratios for the Association between Job

Demands and Work-Related Burnout ...... 115

Table 19. Unadjusted and Adjusted Odds Ratios for the Association between Job

Resources and Work-Related Burnout ...... 117

Table 20. Odds Ratios for the Association between Confounding Variables and Patient-

Related Burnout ...... 119

Table 21. Unadjusted and Adjusted Odds Ratios for the Association between Job

Demands and Patient-Related Burnout ...... 120

Table 22. Unadjusted and Adjusted Odds Ratios for the Association between Job

Resources and Patient-Related Burnout...... 122

Table 23. Proportion of EMS Professionals with High and Low Job Demands and Job

Resources ...... 124

Table 24. Odds of Work-Related and Patient-Related Burnout by Job Demands and Job

Resources Status ...... 124

Table 25. Comparison of All Full Questionnaire and Non-Responder Questionnaire

Participant Characteristics ...... 125

Table 26. Items of the Work-Related Burnout and Patient-Related Burnout Subscales of the Copenhagen Burnout Inventory ...... 152

Table 27. Comparison Responder and Non-Responder Characteristics ...... 159

Table 28. Characteristics of EMS Professionals Included in the Analysis Population

(N=233) ...... 159

xviii

Table 29. Location, Types, Causes, and Medical Attention of Occupational Injuries among EMS Professionals Included in the Analysis Population (N=20) ...... 160

Table 30. Burnout Prevalence among EMS Professionals at Mecklenburg EMS Agency

(N=233) ...... 161

Table 31. Turnover, Sickness Absence, and Occupational Injury for EMS Professionals

Who Experienced Any Burnout Versus Those Who Experienced No Burnout at Baseline

...... 161

Table 32. Prevalence of Turnover, Sickness Absence, and Injury by Burnout Status ... 161

Table 33. Risk Ratios for the Relationship between Burnout and Turnover, Sickness

Absence, and Occupational Injury ...... 162

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List of Figures

Figure 1. Prevalence of work-related and patient-related burnout among nationally- certified EMTs and paramedics24...... 18

Figure 2. Theoretical Framework for an Assessment of Burnout in EMS Based on the Job

Demands-Resources Model and Conservation of Resources Theory ...... 20

Figure 3. Scope of the Job Demands-Resources Model Applied to EMS ...... 25

Figure 4. Scope of the Conservation of Resources Theory Applied to EMS ...... 27

Figure 5. Inclusion of Respondents for Analysis ...... 58

Figure 6. Prevalence of Work-Related Burnout among EMS Agencies with at Least Five

Respondents ...... 65

Figure 7. Prevalence of Patient-Related Burnout among EMS Agencies with at Least Five

Respondents ...... 66

Figure 8. The Relationship between Job Demands, Job Resources, and Burnout ...... 85

Figure 9. Confounding Variables for the Relationship between Job Characteristics and

Burnout in EMS ...... 100

Figure 10. Confounding Variables for the Relationship between Burnout and Workplace

Withdrawal Outcomes ...... 152

Figure 11. Confounding Variables for the Relationship between Burnout and

Occupational Injury ...... 153

Chapter 1. Introduction & Specific Aims

Emergency medical services (EMS) professionals serve a critical public health need, responding to over 28 million emergency calls annually in the United States.1 The

EMS profession is demanding, both physically and psychologically. EMS professionals often work long shifts, exceeding 12 or 24 hours, and perform physically challenging tasks such as moving patients, lifting and lowering stretchers, and carrying heavy equipment.2,3 EMS professionals also experience high mental demands, synthesizing complex information and making time-sensitive decisions in high-risk, uncontrolled environments.4 Further, EMS professionals face intense emotional demands due to frequent exposure to traumatic events, such as situations involving elderly abuse or the death of a child.5,6 The physical, mental, and emotional demands innate to the profession of providing prehospital care could place EMS professionals at high risk for burnout.7

Occupational burnout is a condition characterized by extreme physical and emotional exhaustion that can be attributed to one’s work and often manifests as disengagement or loss of commitment to the job.8 The construct of burnout has evolved over time and many definitions have been proposed. Nevertheless, definitions of burnout commonly include the following elements: emotional exhaustion, symptoms occurring in

“normal” individuals with no history of mental illness, emphasis on psychological symptoms, and results in decreased performance accompanied by negative attitudes towards work.8 Burnout is distinguished from other mental illnesses as this condition is specifically attributable to the work context and extends beyond the constructs of fatigue

1 and exhaustion.9,10 Given the lack of an objective clinical diagnostic test for burnout, the presence of this condition is usually determined through the use of a self-report instrument.

Many instruments have been developed to measure burnout.11 The most commonly used instrument is the Maslach Burnout Inventory (MBI), which consists of three subscales: emotional exhaustion, cynicism (depersonalization) and professional efficacy (lack of personal accomplishment).12 Nevertheless, some have argued that the

MBI subscales of cynicism and professional efficacy do not measure the true construct of burnout, but rather reflect a coping strategy and an effect of burnout, respectively.13

Further, the commercialization of the MBI limits sharing and reproducibility of findings obtained using this tool. Alternatively, the Copenhagen Burnout Inventory (CBI) was introduced in 2005 as a cost-free instrument that is centered on the core burnout characteristics of emotional and physical exhaustion.13 The CBI includes two domains of burnout that apply to individuals who are employed. The first domain, ‘work-related burnout’, is defined as the degree of physical and psychological fatigue and exhaustion that is perceived by the person as related to his/her work.13 The second domain of ‘client- related burnout’ or in the case of healthcare workers, ‘patient-related burnout’, refers to the degree of physical and psychological fatigue and exhaustion that is perceived by the person as related to his/her work with clients/patients.13 While these two domains are part of the same overarching construct of burnout, the prevalence, etiology, and impact of work-related and patient-related burnout likely differ.

Burnout is becoming increasingly prevalent among healthcare professionals and has been linked to important negative outcomes. For example, a survey of over 6,800

2 physicians found that the prevalence of burnout in 2011 was 45.5% and this figure increased to 54.4% by 2014.14,15 In a study of over 68,000 nurses working in hospitals,

34% demonstrated burnout.16 At the level of the individual, burnout has been linked to depression, sleep disturbances, alcoholism, hypertension, and myocardial infarction.17-19

However, burnout also has negative effects at the level of the workplace organization, including increased sickness absence, increased turnover and decreased productivity.20,21

The strong negative impact of burnout among healthcare providers has led to increasing focus on identifying the underlying causes of the condition to aid in the design of interventions to prevent and mitigate its effects.

Among EMS professionals, the estimated prevalence of burnout varies across provider levels. There are four nationally-recognized EMS provider levels, ranging from the emergency medical responder (EMR) level, which requires approximately 40 hours of training to perform basic care such as first aid and cardiopulmonary resuscitation (CPR) to the paramedic level that often entails more than 1,000 hours of initial training and involves the provision of complex, invasive care such as intravenous medication administration and endotracheal intubation.22,23 In a study of over 2,000 nationally- certified EMS professionals, paramedics exhibited greater prevalence of work-related burnout compared to EMTs (30% versus 19%, respectively).24 The prevalence of patient- related burnout was over two times higher among paramedics (14%) compared to EMTs

(6%).24 While this study examined burnout at the individual level among EMS professionals, it is plausible that burnout levels among individuals working for the same

EMS agency who share job resources and demands would be similar. However, no large-

3 scale studies have been conducted to evaluate the prevalence of burnout at the agency level.

Burnout in EMS may negatively impact the well-being of EMS professionals and could also negatively impact the stability of the workforce. The conservation of resources theory postulates that people experiencing the exhaustion central to burnout will attempt to preserve remaining resources.25 Employees may preserve resources by withdrawing from work through sickness absence or leaving the job.26 Previous research conducted among nationally-certified EMS professionals has shown a significant association between burnout and sickness absence and turnover intentions. EMS professionals experiencing work-related burnout demonstrated over a two-fold increase in odds of reporting 10 or more days of sickness absence in the past year and over a three-fold increase in odds of intending to leave the EMS profession within the next 12 months.24

Nevertheless, the outcome measures were self-reported and the investigation was cross- sectional preventing determination of whether burnout occurred before the outcomes of interest.

Rather than retreat from job, employees experiencing burnout may preserve resources by failing to engage in behaviors perceived as non-essential.27 Workarounds, shortcuts, or failure to adhere to safety protocols may, in turn, result in a greater likelihood of committing mistakes and sustaining injury.28 It is well-documented that

EMS professionals are at increased risk for occupational injury and mortality compared to other professions.29-31 However, the underlying causes of occupational injury in EMS are not well understood. Thus, there is a critical need to understand the relationship

4 between burnout and occupational injury among EMS professionals so that effective interventions to reduce injury among this workforce may be developed.

The expected outcomes upon completion of this work are a visualization of variation in burnout levels between agencies, a list of modifiable job-related characteristics associated with burnout, and an estimate of the strength of the relationship between burnout and variables that negatively impact EMS workforce stability. The results of this study will help key stakeholders, including federal government agencies,

EMS state officials, medical directors, and agency leadership, understand the burden and impact of burnout on EMS professionals and EMS agencies. The long-term goal of this project is to develop and implement interventions that improve the well-being of the

EMS workforce and ultimately, the outcomes of the patients served. To move towards this goal, the specific aims of this study are three-fold:

1.1 Specific Aims

1. Quantify the prevalence of work-related and patient-related burnout at the

EMS agency level and identify agency characteristics associated with each

type of burnout.

We hypothesized that burnout levels vary between EMS agencies and that

burnout levels are associated with agency characteristics (e.g., agency

type, agency call volume).

2. Identify job demands and resources associated with work-related and

patient-related burnout.

We hypothesized that job demands are associated with greater odds of

work-related and patient-related burnout and that job resources are

associated with reduced odds of work-related and patient-related burnout.

3. Quantify the link between burnout and turnover, sickness absence, and

occupational injury among EMS professionals.

We hypothesized that EMS professionals experiencing the physical and

emotional exhaustion central to burnout would be at higher risk for

turnover, sickness absence, and occupational injury.

Chapter 2. Background and Significance

2.1 Emergency Medical Services Professionals and the Prehospital Setting

Emergency medical services (EMS) professionals represent a critical initial link in the healthcare continuum, providing life-saving care for acutely ill or injured patients in the prehospital setting responding.1 In some settings, EMS professionals also fill gaps in local health care infrastructure and provide non-emergent services, such as post-discharge care, home safety assessments, and wound care.32 As there is no national database of every licensed EMS professional in the country, estimating the total number of prehospital providers is challenging. In 2014, the Bureau of Labor Statistics estimated that there were 241,200 EMS professionals in the U.S., and that number is expected to grow over 25% by 2024.33 However, the estimates from the Bureau of Labor Statistics do not take into account the volunteer EMS workforce, which remains important in the profession of prehospital care.34 Meanwhile, the 2011 National EMS Assessment, which did include volunteers, estimated that there were over 826,000 credentialed EMS professionals.35

The educational requirements and scope of practice for EMS professionals differ by provider level. While practice and credentials differ greatly from state to state, there are four nationally-recognized provider levels: emergency medical responder (EMR), emergency medical technician (EMT), advanced emergency medical technician (AEMT), and paramedic. EMR courses typically range from 40 to 60 hours and train individuals to provide basic life support care including first aid and cardiopulmonary resuscitation

(CPR).22 Meanwhile, paramedic education programs must be accredited and are often two or four year degree programs lasting over 1,000 hours.36 Paramedics are able to deliver advanced interventions in the prehospital setting including intravenous medication administration and cardiac monitoring.23

2.2 Work Stress in EMS

The prehospital setting differs greatly from that of other healthcare professions and EMS professionals face unique stressors. While hospital care usually occurs in a controlled, clean room with limited access for non-hospital employees, prehospital care can occur in any setting including residences, public venues, or the side of the road.1

Unlike the hospital environment, where staff typically work with the same teammates day in and day out, the prehospital setting is often unpredictable and EMS crewmembers have frequently met for the first time at the beginning of a shift.2 EMS professionals of different backgrounds, experiences, and training must work together, commonly in teams of two, to make time-sensitive treatment decisions and transport patients to definitive care.37 The unique nature of the prehospital setting further generates distinct job demands among EMS professionals.

EMS is a physically, mentally, and emotionally demanding profession requiring critical decision-making in high-risk, time-sensitive settings. EMS professionals routinely perform physical tasks such as bending, twisting, lifting patients, and carrying heavy equipment.38 Other potentially hazardous tasks include operating emergency vehicles at high speeds and administering medications intravenously.38 Mentally-demanding tasks include complex medication dose calculations under time pressure for critical illnesses or injuries.39 Emotional demands include frequent exposure to traumatic events.5 Distressing

8 events commonly witnessed by EMS professionals include the death of a child, elderly abuse, and incidents involving multiple casualties, such as when an entire family is killed in an automobile accident.6

Fatigue is another important stressor as EMS professionals often work long shift hours and manage multiple jobs, often with insufficient periods of rest.2,40 EMS professionals frequently work shifts lasting 12 or 24 hours with variable work load and sleep time.40 In a study of nearly 2,000 nationally-certified EMTs and paramedics, over two-thirds of the sample suffered from at least one of seven sleep problems evaluated in the study, with the most common condition being sleep onset disorder affecting 50% of the sample.41 The cumulative effect of these exposures to acute and chronic stressors may place EMS professionals at high risk for occupational burnout.7

2.3 Occupational Burnout Definition

The term “burnout” first appeared in the early 1970s and was used to describe a number of important psychosocial problems primarily among individuals who work with people.13 In 1974, Freudenberger used the term to describe the concerning physical and behavioral effects he observed among workers at a free clinic in New York including fatigue, exhaustion, transformation into the “house cynic”, and spending more and more hours at work while accomplishing less.42 Shortly afterwards in 1976, Maslach and her colleagues independently defined burnout as “a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do ‘people work’ of some kind”.43

Throughout the 1970s, the number of burnout studies grew quickly and varying definitions of burnout were used. Perlman and Hartman summarized the definitions of

9 burnout published in 48 investigations between 1974 and 1980 as, “a response to chronic emotional stress with three components: (a) emotional and/or physical exhaustion, (b) lowered job productivity, and (c) overdepersonalization.”44 During this time the concept of burnout also began to be extended to professions outside of the human services sector.45 Accordingly, Maslach refined the definition of burnout in a more general sense that could be applied to a wider range of professions as “a state of exhaustion in which one is cynical about the value of one’s occupation and doubtful of one’s capacity to perform.”43

While the concept of burnout and its definitions have evolved over time, the focus of the construct has remained centered on a depletion of energetic resources resulting in physical and mental exhaustion.46 There are five elements common to most definitions of burnout: i) emotional exhaustion, ii) emphasis on mental and behavioral symptoms, iii) generally related to work, iv) symptoms occur in “normal” individuals with no history of mental illness, v) decreased effectiveness and poor work performance accompanied by negative attitudes towards work.8

Controversy exists over whether burnout is truly a distinct construct from other facets of mental well-being such as depression, job satisfaction or fatigue. A confirmatory factor analysis of the Beck Depression Inventory and the Maslach Burnout Inventory showed burnout and depression as two separate domains, suggesting that burnout is distinct from, yet related to, anxiety and depression.10 Burnout is specific to the work context whereas depression is context-free and pervades every dimension of a person’s life.21 While the central characteristic of burnout is related to exhaustion, the construct of burnout is multidimensional and extends beyond fatigue and exhaustion.9 Most

10 instruments used to measure burnout contain two or more separate subscales to measure distinct domains of the condition.

2.4 Measurement of Burnout

Since its conceptualization, many tools have been developed and used to measure burnout. In a 1993 review of the measurement of burnout, Shaufeli et al. identified over

20 instruments used for evaluating burnout.47 The following paragraphs describe two of the most commonly used instruments: the Maslach Burnout Inventory and the

Copenhagen Burnout Inventory.

Maslach Burnout Inventory

The most widely employed tool for measuring burnout is the Maslach Burnout

Inventory (MBI), which by some estimates has been used in more than 90% of empirical burnout studies worldwide.48 The MBI measures burnout in three domains: emotional exhaustion (a drained or depleted feeling arising because of excessive psychological and emotional demands), depersonalization (a tendency to view others in an excessively detached, impersonal manner), and lack of personal accomplishment (a sense of incompetence and lack of achievement).43 The original MBI-Human Services Survey

(MBI-HSS) consisted of 22 items.49 Afterwards, the 16-item MBI-General Survey (MBI-

GS) was introduced in 1996 to measure burnout in occupational groups other than public human service providers.43 The emotional exhaustion component was modified to exhaustion, depersonalization was replaced by cynicism (indifference or a distant attitude towards work), and personal accomplishment was changed to professional efficacy to encompass both social and nonsocial aspects of occupational accomplishments.43 The three subscales of the MBI have been shown to have acceptable internal consistency

11 across a number of professions throughout the world with Cronbach’s α values ranging from 0.71 to 0.90.47 Further, in a meta-analysis of confirmatory factor analyses of the

MBI, 18 of 21 studies supported the three subscale model.50,51

Despite its wide use, the MBI has important disadvantages, the first being that the instrument has been commercialized and licenses for each administration of the tool are distributed by a private company.52 As such, items from the MBI cannot be published in scientific journals and shared freely to foment further research. Further, some have posited that the depersonalization/cynicism subscale of the MBI is actually a coping strategy while the subscale pertaining to loss of professional efficacy is an effect of burnout syndrome.13 Due to the financial and theoretical limitations of the MBI, many have sought additional tools to measure burnout.

Copenhagen Burnout Inventory

The 19-item Copenhagen Burnout Inventory (CBI) was created as an alternative to the MBI. The CBI consists of three dimensions: personal burnout (the degree of physical and psychological fatigue and exhaustion experienced by the person), work- related burnout (the degree of physical and psychological fatigue and exhaustion that is perceived by the person as related to his/her work), and client-related burnout (the degree of physical and psychological fatigue and exhaustion that is perceived by the person as related to his/her work with clients).13 The first domain is intended to be a general scale that applies to all individuals, whether employed or not. Work-related burnout applies specifically to one’s occupation and client-related burnout is intended to measure burnout among those whose job involves working with clients, or in the case of healthcare professionals, patients.

The CBI has shown high internal reliability with Cronbach’s alpha of 0.85 in the client-related domain and 0.87 in the personal and work-related domains.13 The test-retest reliability coefficient assessed among a cohort of intensive care unit nurses in Iran 14 days apart was 0.86, which indicates stability in responses.53 In a study directly comparing the two instruments, it was demonstrated that the psychometric properties of the CBI were equivalent to those of the MBI.54 Both instruments demonstrated high internal reliability coefficients (MBI: 0.73-0.93; CBI: 0.79-0.89).54 The MBI classified

15.5% of the population as having high burnout while this figure was 16.0% for the CBI in the same population.54 The CBI has further shown adequate reliability among a sample of nationally-certified EMS professionals as the Cronbach’s alpha for the work-related and patient-related domains were 0.89 and 0.91, respectively.24

2.5 Prevalence of Burnout in Healthcare Professions

Healthcare professions are demanding and rewarding; however, chronic exposure to stressors may lead to increased professional burnout, which could contribute to negative outcomes for both patients and providers. In 2011, a study of over 7,200 physicians selected from the physician master file maintained by the American Medical

Association found that, compared to a probability-based sample of working adults, physicians were more likely to demonstrate symptoms of burnout.55 In a 2014 study of more than 6,800 physicians selected from the physician master file, 54% experienced burnout.15 This number represents a significant increase from the 46% of physicians experiencing burnout in 2011 (p<0.001).15 Burnout was most prevalent among physicians with the specialty of emergency medicine (70%), which may reflect the demanding high- stress, time-sensitive nature of the work in the emergency department.15 Burnout

13 prevalence is also high among hospital nurses as a study of more than 68,000 nurses found that 34% demonstrated burnout.16 In a study of more than 10,000 staff nurses in

Pennsylvania, 43.2% demonstrated high levels of burnout.56 Meanwhile, a systematic review of 17 studies involving emergency room nurses found an average burnout prevalence of 26%.57 The use of different tools to measure burnout and different cut points to determine the presence of the condition makes comparing findings between studies challenging.

2.6 Negative Effects of Burnout on the Well-Being of Healthcare Professionals

Burnout has been linked to a number of negative consequences in healthcare professions at the individual level and at the level of the workplace organization. For individuals, burnout has been associated with clinically significant mental and physical health problems. In a study of Swedish workers, mostly comprised of nurses, those experiencing burnout were more likely to report sleep disturbances (32% vs. 9%) and rate their overall health as poor (27% vs. 6%) compared to those not experiencing burnout.58

In a study of Turkish nurses, higher levels of burnout were linked with more psychosomatic symptoms and lower levels of positive affect.59 In another study involving a convenience sample of emergency nurses in Egypt, burnout was positively correlated (r=0.34) with musculoskeletal disorders.60 Among physicians, burnout has been linked to negative health effects including headaches, sleep disturbances, hypertension, anxiety, and myocardial infarction.19 In a study of over 7,000 surgeons in the US, those with high levels of burnout had 1.25 times the odds of reporting alcohol abuse or dependence compared to their counterparts who did not demonstrate burnout.61

Surgeons experiencing burnout also had 1.91 times the odds of suicidal ideation compared to those who did not exhibit burnout.62

As burnout may negatively impact individual employees, this condition may also have deleterious consequences at the level of the workplace organization. Burnout is strongly associated with two major factors that negatively impact workplace organizations: sickness absence and turnover.13,20 A prospective study of industrial workers in Finland found that burnout increased the risk of workplace absence due to mental disorders, diseases of the circulatory system, diseases of the respiratory system, and diseases of the musculoskeletal system.63 Meanwhile, Campbell et al. found a strong correlation between burnout and intent to retire early among surgeons.64 Additionally, a link between burnout and anticipated turnover has been demonstrated among nurses.53,65

While burnout may drive some workers to leave their places of employment or call in sick, others will stay on, but perform only the bare minimum requirements of the job.21 This decline in commitment to the job, productivity and quality of work associated with burnout hurts not only the organization, but also those served by the organization.21

In the context of healthcare, burnout and the associated disengagement and lack of commitment to the job could have serious negative consequences for patient and provider safety.

2.7 Burnout and Safety and Injury in Healthcare

Burnout has been linked to negative safety outcomes for patients and providers. In a study of nearly 6,000 physicians and nurses in Belgium, those involved in patient safety incidents demonstrated 2.07 times the odds of exhibiting burnout compared to physicians not involved in patient safety incidents.66 A study of nearly 8,000 physicians in the US

15 showed that for every one point increase on the MBI depersonalization scale, there was an 11% increase in likelihood of reporting a patient care error, while for every one point increase in the emotional exhaustion scale there was a five percent increase of reporting an error.67 In a prospective cohort study of medical residents at Mayo Clinic Rochester, high levels of depersonalization and exhaustion measured with the MBI were associated with increased odds of a self-perceived major medical error within the subsequent three month period.68 In a sample of Canadian nurses, a relationship between increased burnout and an increased number of adverse events including patient falls, nosocomial infections, medication errors and complaints was found.69

In addition to its association with patient care errors, the disengagement from work associated with burnout may negatively affect healthcare providers’ performance and quality of medical services provided.70 Burnout was further associated with self- reported suboptimal patient care in a group of internal medical residents.71 Similarly, in a study of nurses from six countries increases in emotional exhaustion and depersonalization measured using the MBI were associated with significantly greater odds of reporting fair/poor quality of patient care provided during the previous shift.72

Additionally, healthcare providers experiencing burnout may be at higher risk of injury on the job.73 In a study involving a sample of 222 health professionals from a large teaching hospital in the US, exhaustion was associated with greater likelihood of safety workarounds (shortcuts), which then lead to greater frequency and severity of occupational injuries.27 In a study of 789 nurses working in 11 US cities, those who scored high on the emotional exhaustion scale of the MBI demonstrated 2.08 (95% CI:

1.03-4.19) times the odds of sustaining a needlestick injury compared to those who

16 scored medium or low on the subscale.74 Higher levels of burnout were found among nurses in China who had received a needlestick injury.75 There is a paucity of literature evaluating the association between burnout and other types of occupational injury among healthcare professionals including sprains, strains, and fractures.

2.8 Burnout among EMS Professionals

A 1988 study by Grigsby and McKnew found substantially higher rates of burnout among a group of paramedics in South Carolina compared to nurses.76 Stassen et al. surveyed a group of ALS paramedics in South Africa and found that 63% exhibited some degree of burnout.77 Another study based on a convenience sample of volunteer

EMS personnel in New York found that nearly all participants scored ‘high’ on the MBI depersonalization (99.3%) and emotional exhaustion (92.0%) components.78 A study of nationally-certified EMS professionals using the CBI found that the estimated prevalence of work-related and patient-related burnout was greater among paramedics than EMTs

(Figure 1). The higher prevalence of burnout among paramedics in all three burnout dimensions may be attributed to the greater stress associated with performing more critical and invasive tasks at this most advanced EMS provider level.

50%

40%

30.1% 30% 19.1% EMT 20% 14.4% Paramedic

10% 5.5%

0% Work-Related* Patient-Related*

Burnout Dimension

*p<0.05

Figure 1. Prevalence of work-related and patient-related burnout among nationally- certified EMTs and paramedics24

Burnout has the potential to negatively impact the health and safety of EMS professionals; however, few studies have quantified its impact. A study of 99 EMS professionals at a single agency in the Midwest found a significant correlation between burnout and turnover (r=0.55, p<0.05).79 The link between burnout and turnover in EMS was further supported by a study of over 2,000 nationally-certified EMS professionals in which work-related burnout was associated with over a three-fold increase in turnover intentions (OR: 3.37, 95% CI: 2.67-4.26). Work-related burnout was further associated with over a two-fold increase in odds of reporting 10 or more days of sickness absence over the past 12 months (OR: 2.30, 95% CI: 1.39-3.83).24 Nevertheless, the data from this study were limited by the cross-sectional nature of the investigation and the self-reported data.

Burnout may also be related to occupational injury in EMS. A study of firefighters in Greece found that more of those scoring medium or high on the MBI

18 emotional exhaustion component (14%) sustained an occupational injury compared to those who scored demonstrated a low level of emotional exhaustion (8%, p<0.05).80

Another study of 220 male career firefighters in France found a significant negative relationship between the number of injuries and emotional exhaustion (β= -0.11, p<0.01).81

2.9 Occupational Injury in EMS

EMS professionals provide care in uncontrolled settings to seriously ill or injured patients and are at high risk of occupational injury and mortality. Occupational hazards commonly faced by EMS professionals include needlestick injuries and exposure to infectious disease, collisions involving emergency vehicles, physical injury, assault from patients or bystanders.82 From 1999 to 2005, the rate of injuries and illnesses that required treatment at the emergency department was estimated at 8.6 per 100 EMS professionals, which was more than four times higher than the rate among all workers.30

The rate of occupational injuries and illnesses resulting in at least one missed workday was 8.1 per 100 EMS professionals per year.31 The most common non-fatal injuries were incurred as a result of body motion, followed by exposures to harmful substances including body fluids or toxic chemicals.30 Between 2003 and 2007, the fatality rate for compensated EMS professionals was 6.3 per 100,000 providers, which was nearly one- and-a-half times greater than that among all workers during the same time period.29 The most common causes of fatal occupational incidents were ground or air transportation incidents.29

2.10 Theoretical Framework

The first two aims of this project were guided by the job-demands resources model.83 This portion of the research consisted of a cross-sectional questionnaire administered to EMS professionals in South Carolina. The third aim was guided by the conservation of resources theory.84 This portion of the research consisted of a prospective observational study conducted at a large, county-based EMS agency in North Carolina.

Figure 2 displays an overview of the theoretical framework for this study combining the job demands-resources theory and the conservation of resources theory.

Figure 2. Theoretical Framework for an Assessment of Burnout in EMS Based on the Job Demands-Resources Model and Conservation of Resources Theory

2.10.1 Job Demands-Resources Model

The first theory used to guide this project is the job demands-resources model of burnout.83 The job demands-resources model states that all job characteristics can be categorized into one of two groups, either job demands or job resources. Job demands are defined as physical, social, or organizational aspects of the job that require sustained physical or mental effort or costs.83 Examples of job demands include physical workload, time pressure, demanding contact with recipients of services, unfavorable shift work schedules, and the physical environment. On the other hand, job resources are physical, social, or organizational aspects of the job that are functional in achieving work goals, reduce job demands and the associated physiological or psychological costs, and/or stimulate personal growth, learning and development.83 Examples of job resources include performance feedback, rewards, high job control, participation in decision- making, job security and supervisor support.

The job demands-resources model postulates that there are two primary processes at work with regards to the impact of job demands and job resources. First, high job demands lead to a depletion of employees’ mental and physical resources increasing the likelihood of developing burnout.83 Second, access to job resources has a motivational impact and may serve to mitigate the impact of job demands on burnout through increased work engagement.85 This theory has been supported as a meta-analysis of 64 samples from various occupations found a significant positive correlation between job demands and burnout (r=0.27, p<0.05), while job resources were negatively related to burnout (r=-0.27, p<0.05).86 A study among 805 Finnish teachers found that job resources are particularly important in mitigating burnout under stressful conditions when

21 job demands are high, such as when there is a high level of stress due to student misconduct.85

Other popular models of occupational stress and burnout exist, including the effort-reward imbalance model and the demand-control model. The effort-reward imbalance model suggests that job strain results from an imbalance between the resources being given by the employee to meet job demands (effort) and what is received in return, including pay and benefits (rewards).87 Meanwhile, the demand-control model posits that job strain is caused by high job demands and low job control.88 While both of these models acknowledge the importance of job demands in generating job strain, these models differ in the specific characteristics that are emphasized. The first model focuses on the role of monetary and non-monetary rewards, while the second model focuses on autonomy over one’s work. Neither of these models acknowledges that the job characteristics that are most important in generating job strain are likely to vary from one occupation to another. Whereas having autonomy to choose how to accomplish a task may be important for a person working in customer service, autonomy is less likely expected or desired for an airline pilot preparing to land an aircraft. The job demands- resources model integrates the concepts of the demand-control and effort-reward imbalance models and expands to say that the job characteristics that rank most important in contributing to burnout will vary depending on the specific occupation under study.85

Because of this flexibility to assess a variety of job characteristics, the job demands- resources model was selected to guide this study.

Since its development, the job demands-resources model has been used in hundreds of empirical studies and has been used by thousands of organizations to

22 improve employee well-being.89 To improve the effectiveness of interventions aimed to reduce burnout, it is first necessary to identify which characteristics are most strongly tied to the condition in the particular setting under study. The job demands-resources model has been used in a variety of healthcare settings to identify the characteristics that are strongly tied to burnout and engagement. For example, in a systematic review of burnout among emergency nurses, job-related characteristics that were been found to have an association with burnout included: high workload, low level of job control, and lack of support from the organization’s leadership.57 A study of over 10,000 nurses in the US,

Canada, England and Scotland showed that organizational characteristics such as lack of autonomy and lack of leadership support were associated with a two-fold increase in odds of emotional exhaustion as measured by the MBI.90 In a study of 99 EMS professionals from a single Midwestern agency, the job demands of work hours (% of R2=2.07%), strain (% of R2=2.35%), and autonomy (% of R2=9.48%) were significantly associated with burnout.79 Further, the different domains of burnout may be associated with different job demands and resources. In a study of 1,636 Canadian nurses, job demands were the most important predictors of the emotional exhaustion scale of the MBI whereas job resources were more strongly associated with depersonalization.91

In addition to helping identify job characteristics most strongly linked to burnout, the job demands-resources model has been used to link job demands and burnout to negative outcomes for the individual and organization. After linking job demands and resources to the MBI emotional exhaustion and depersonalization subscales, Jourdain and

Chenevert found that both burnout scales were significantly related to the intention to leave the nursing profession.91 Notenbomer et al. used the job demands-resources model

23 to explore factors related to frequent sickness absence using focus groups.92 Determinants of frequent sickness absence identified included high work pressure, irregular work shifts and lack of social support and dissatisfaction with supervisors.92 Nahrgang et al. conducted a meta-analysis using 203 independent samples and found support for the job demands-resources model relating job demands to burnout and negative safety outcomes.28 Job demands classified as risks and complexity were positively associated with burnout (r=0.28, r=0.24, respectively) and burnout was significantly related to adverse events (r=0.29) and injuries (r=0.13), although this correlation was not strong.28

Nevertheless, future research is needed to quantify the association between burnout and important outcomes such as injury, after controlling for confounding variables.

Aim 1 of this project is guided by the concept that job demands and resources among EMS professionals working for the same agency are likely to be similar. Since demands and resources vary widely from one EMS agency to another, we expected that burnout levels would vary across agencies. Further, certain agency characteristics, such as the agency type (e.g., fire-based, hospital-based, private) and community size served are associated with the availability of job resources (e.g., salary, benefits) and demands

(e.g., patient presentations, volume of responses). Aim 2 of this research sought to quantify the relationship between specific job demands and resources with burnout in

EMS. Figure 3 displays how the job demands-resources model was be applied to burnout at EMS agencies for aims 1 and 2 of this work.

Figure 3. Scope of the Job Demands-Resources Model Applied to EMS

2.10.2 Conservation of Resources Theory

The second theory used to guide this work was the conservation of resources theory. Originally conceived in 1989 by Stevan Hobfoll, the conservation of resources theory was created to conceptualize the development of stress.84 The core concept of this theory is that people strive to maintain and gain resources. Resources are defined as objects (things that have a physical presence), conditions (structures or states, such as social relationships), personal characteristics (individual traits or coping skills), or energies (skills and abilities that can be exchanged for other resources) that the individual values.84 In this theory, stress is defined as a situation where there is an actual or perceived loss or lack of gain of resources.84 The three conditions resulting in stress are:

1) the threat of a net loss of resources, 2) the net loss of resources, and 3) a lack of resource gain after resources have been invested.84

The conservation of resources theory was later extended beyond the conceptualization of stress and applied to burnout as a special form of stress characterized primarily by emotional exhaustion.93 In this application, burnout results when high demands and insufficient resources over time wear down the employee’s energetic resources.94 The employee then engages in behaviors to preserve existing resources and is less willing to invest resources in work. Employees experiencing burnout may choose to withdraw from work in order to preserve resources, either by taking days off (sickness absence) or by leaving a job (turnover).25 Previous work conducted among a sample of prison guards supported this hypothesis as resource depletion was significantly associated with burnout, and burnout was associated with increased absenteeism.95

Instead of withdrawing from work, employees may choose to remain on the job and conserve resources by not investing energies in work deemed non-essential.26 Thus, employees experiencing burnout may seek ways to complete work faster or in less steps than what the workplace protocols specify. In 2007, Halbesleben found support for this theory as burnout was positively correlated with failure to adhere to safety protocols

(workarounds) and with higher occupational injury.27 Aim 3 of this work is guided by the conservation of resources theory to assess burnout and its relationship with turnover, sickness absence, and occupational injury (Figure 4).

Figure 4. Scope of the Conservation of Resources Theory Applied to EMS

2.11 Innovation & Significance

Traditionally, much attention has been focused on the causes of burnout at the level of the individual worker and interventions have primarily focused on changing the individual to reduce burnout by reducing stress and/or improving the individual’s coping skills.96 Nevertheless, job characteristics common at the level of the workplace organization may have a strong impact on employee burnout. By identifying these job- related characteristics, large-scale workplace interventions may be developed that could have a greater impact than interventions that focus solely on individual workers. Further, identifying job characteristics related to burnout may lead to a more effective intervention strategy as changing the job situation may be more feasible and have a larger lasting impact than changing the individual.21 Thus, this study is innovative in that it seeks to identify variables that do not reflect a character flaw of an individual, but rather constitute an area where workplace change could have a large positive impact on preventing or ameliorating burnout among employees.

Finally, burnout has demonstrated a strong link with many negative outcomes across various populations of healthcare professionals, yet the association between burnout and illness and injury in EMS has not been evaluated in detail. Aim 3 prospectively evaluates the link between burnout and the outcomes of turnover, sickness absence, and occupational injury. Quantifying the link between burnout and these outcomes that negatively impact workforce stability, may lead to interventions to reduce burnout and improve the health and safety of this critical healthcare workforce.

Chapter 3. Research Design and Methods

3.1 Overview

The aims of this study included: 1) quantifying the prevalence of burnout at EMS agencies and identifying associated agency characteristics, 2) identifying specific job- related characteristics associated with burnout, and 3) assessing for a relationship between burnout and turnover, sickness absence, and occupational injury. An electronic survey of EMS professionals in South Carolina was used to answer Specific Aims 1 and

2, while a prospective cohort study of EMS professionals at a large, county-based agency in North Carolina was used to answer Specific Aim 3.

This chapter provides an overview of the research design and analysis methods.

Chapters 4 through 6 provide detailed descriptions of the procedures used for each study.

Research protocols were drafted separately for the questionnaire-based research and the prospective cohort study. For both investigations, the institutional review board at The

Ohio State University ceded oversight to the institutional review board at the American

Institutes for Research. The institutional review board at the American Institutes for

Research approved all study procedures and granted a waiver of documented consent for both investigations.

3.2 Specific Aims 1 & 2: Study Setting

Ideally, the target population for this research would have included all practicing

EMS professionals in the United States; however, there is no registry of every licensed,

29 practicing EMS professional in the country, limiting the feasibility of generating a sampling frame that would encompass this target population. Instead, we decided to seek a statewide database of licensed EMS professionals in order to have an enumerable study population of EMS professionals that would encompass a broad range of practice settings.

The South Carolina Department of Health and Environmental Control’s Bureau of

EMS maintains a complete registry of all licensed EMS through an electronic credentialing information system.97 The South Carolina Bureau of EMS further maintains a registry of all EMS agencies in the state and EMS agencies are required to submit and maintain rosters of their active employees to the credentialing information system.98 In

2016, there were approximately 4,000 EMTs, 500 AEMTs, and 2,900 paramedics who worked for a total of 217 EMS agencies.99 About 30% of EMS agencies operated in rural settings.99 In 2017, there were 1,361,958 EMS responses, of which 56.5% were 911 calls, for nearly five million SC residents.99,100

3.3 Specific Aims 1 & 2: Instrument Development

We developed a survey instrument to assess burnout and job characteristics among EMS professionals. Burnout was measured using the work-related and patient- related burnout subscales from the Copenhagen Burnout Inventory (CBI) adapted for

EMS (Table 1). Both the work-related and patient-related subscales have demonstrated acceptable internal consistency among a random sample of nationally-certified EMS professionals in the U.S. with a Cronbach’s alpha of 0.89 and 0.91, respectively.24 Job characteristics were assessed using items from existing instruments, such as the safety

30 attitudes questionnaire101, the surveys on patient safety culture (SOPS™)102,103, and newly developed items specifically for this study.

Before finalizing the survey instrument, we cognitively tested the questionnaire with 10 practicing EMS professionals. Cognitive debriefing consists of pilot testing the questionnaire and using specifically designed probes administered by an interviewer to assess readability and consistency in interpretation of the items.104 We aimed to recruit participants for the cognitive interviews from a variety of practice settings and experience levels. Table 2 displays the characteristics of the cognitive debrief participants. Based on the results of these cognitive interviews, minor edits were made to the wording of items before deploying the questionnaire to the study population. Appendix A contains the final survey instrument.

Table 1. Items of the Work-Related and Patient-Related Burnout Subscales of the Copenhagen Burnout Inventory Adapted for EMS Work Related Burnouta 1. “I felt worn out at the end of the working day.” 2. “I was exhausted at the beginning of my shift at the thought of another day at work.” 3. “I felt that every working hour was tiring.” 4. “I had enough energy for family and friends during leisure time.”* 5. “My work is emotionally exhausting.” 6. “My work frustrated me.” 7. “I felt burned out because of my work.” Patient-Related Burnouta 1. “I found it hard to work with patients.” 2. “I found it frustrating to work with patients.” 3. “It drained my energy to work with patients.” 4. “I felt that I give more than I get back with patients.” 5. “I was tired of working with patients.” 6. “I wondered how long I will be able to continue working with patients.” aResponse scale: Always or almost always, Often, Sometimes, Seldom, Never or almost never *Reverse coded

Table 2. Characteristics of Cognitive Debrief Participants (N=10) % (n) Sex Female 20% (2) Male 80% (8) Certification Level EMT 40% (4) Paramedic 60% (6) Agency Type Fire Department 40% (4) Governmental, Non-Fire 30% (3) Private, Non-Hospital 30% (3) Years of EMS Experience Less than 3 years 30% (3) 3 to 10 years 40% (4) More than 10 years 30% (3) Community Size Urban 90% (9) Rural 10% (1)

3.4 Specific Aims 1 & 2: Data Collection

E-mail addresses for every licensed provider listed on one or more South Carolina

EMS agency rosters were obtained from the state credentialing information system. This list was de-identified as each e-mail address was assigned a random identification number that allowed for merging of survey results with agency characteristic information obtained from the state credentialing information system. EMS professionals listed on more than one agency roster were assigned a single identification number and did not receive multiple invitations to participate in the survey. A census survey was conducted instead of a sample survey since there was no increase in cost or required resources associated with inviting a larger number of EMS professionals to participate in an electronic questionnaire. All survey data were collected using the electronic survey software SurveyGizmo (Widgix LLC; Boulder, CO).

In an effort to increase response rate, a pre-notification e-mail was sent from the

Chief of the South Carolina Bureau of EMS one week prior to survey deployment

(Appendix B). This e-mail also contained a flyer with information regarding the importance of the study (Appendix C). Support from an authoritative source has been shown to improve response rates to surveys.105 An e-mail containing a link to the questionnaire was distributed to all licensed EMS professionals in the state of South

Carolina. In addition to the survey link, the e-mail contained an explanation of an individual’s rights as a participant and a statement regarding the voluntary nature of the study with no bearing on an individual’s South Carolina license to practice EMS

(Appendix D). Following Dillman’s tailored design method, two reminder e-mails were sent at seven and 14 days after the initial e-mail invitation.106 According to the tailored design method, repeated, appropriate contact with respondents serves to improve response rates over a single contact.106 As an additional incentive to participate, respondents were included in a raffle to win one of ten Amazon gift cards worth $100 each.

3.5 Specific Aims 1 & 2: Non-Responder Survey

Based on results from previous surveys among nationally-certified EMS professionals, we anticipated a response rate of approximately 20%.24,107,108 To assess for potential response bias, an electronic non-responder survey was conducted. This abbreviated survey was designed to take less than five minutes to complete. Items of the non-responder questionnaire included the work-related burnout subscale of the

Copenhagen Burnout Inventory and key demographic characteristics, including sex, certification level, EMS experience, and employment status. An invitation to participate

33 in the non-responder survey was sent to all EMS professionals who did not respond to the full questionnaire. Based on previous work among the nationally-certified population of

EMS professionals, we expected the response rate to the non-responder survey to be between one and three percent.107 Despite the low anticipated response rate to the abbreviated survey, we felt conducting a non-responder survey would provide some valuable insight into the magnitude and direction of potential response bias. Frequently, survey researchers use late responders as a proxy for non-responders.109 As such, the abbreviated non-responder survey represents a means to obtain information from a more extreme form of late responders.

3.6 Specific Aim 1: Analysis

The objectives of the first study were to quantify the prevalence of work-related and patient-related burnout at the agency level and identify agency characteristics associated with the prevalence of each type of burnout. The analysis population consisted of all currently practicing EMS professionals certified at the EMT, AEMT, or paramedic levels who provided patient care in the 30 days preceding the study.

The primary outcome measures for Specific Aim 1 were the prevalence of work- related and patient-related burnout at each EMS agency. Burnout was measured using the

Copenhagen Burnout Inventory and the prevalence of each type of burnout was calculated as the proportion of EMS professionals exhibiting burnout in the domain divided by the total number of respondents from each agency. To provide more stable estimates, analysis was restricted to agencies with five or more respondents. A subgroup analysis of agencies with fewer than five respondents was conducted to assess for possible bias introduced by excluding agencies with fewer respondents.

Seven agency characteristics were assessed for an association with burnout prevalence: 1) service level, 2) agency type, 3) primary service provided, 4) community size, 5) annual call volume, 6) number of EMS employees, and 7) vehicle count. Agency characteristics were obtained from the South Carolina credentialing information system and participants were linked to their EMS agencies using a unique identifier assigned at the start of the study. The median burnout prevalence was computed for each level of each agency characteristic. Median burnout prevalence was then compared across agency characteristics using Wilcoxon Rank Sum tests for dichotomous variables and Kruskal

Wallis tests for variables with three or more levels.

3.7 Specific Aim 2: Analysis

Specific Aim 2 focused on quantifying the relationship between specific job- related characteristics and each type of burnout. Again, burnout was measured using the work-related and patient-related subscales of the Copenhagen Burnout Inventory. Six categories of job demands were assessed: 1) physical workload, 2) time pressure, 3) patient contact, 4) physical environment, and 5) shift work. There were also six categories of job resources assessed: 1) performance feedback, 2) rewards, 3) job control,

4) participation, 5) supportive environment, and 6) knowledge. Categories of job demands and resources were selected based on previous work by the authors of the job demands-resources theory.83

Generalized estimating equation (GEE) models were used to estimate the odds of burnout associated with each job characteristic separately while taking into account clustering at the EMS agency level. A working exchangeable correlation structure was used for these models, since this structure results in consistent estimates of the

35 coefficients.110 A logit link and Bernouilli variance were used to estimate odds ratios for burnout for each job demand and job characteristic separately. Each model was then adjusted for confounding variables selected a priori. A total of five confounding variables were included: 1) certification level, 2) EMS experience, 3) full-time employment status, 4) agency type, and 5) community size.

We chose to include confounding variables selected a priori, rather than using backwards or forwards selection approach to model building, since odds ratios are non- collapsible. Non-collapsibility described in Simpson’s paradox means that if a variable is included in a model, but is not part of the causal structure, the estimated odds ratios will not be the same as if the variable was not included.111 To avoid introducing variables that are not part of the causal structure and biasing estimated odds ratios, we included only those confounders that are justified through substantive reasoning.

Next, the presence of job demands and resources were assessed together following an approach similar to that undertaken in the Whitehall II study.112 A composite variable was created for total job demands by adding up response options for each job demand. The median job demand score for the analysis population was calculated. EMS professionals were classified as having high job demands if their job demand composite score exceeded the median for the analysis population or low otherwise. The same approach was taken to determine the presence of high or low job resources for each EMS professional. A four-level variable was created for providers who experienced: 1) low demands/high resources, 2) low demands/ low resources, 3) high demands/ low resources, and 4) high demands/ high resources. The unadjusted and

36 adjusted odds of each type of burnout were estimated based on job demands and resources exposure status.

3.8 Specific Aim 3: Study Setting

The study setting for the third aim consisted of all EMS professionals working for

Mecklenburg EMS Agency. Mecklenburg EMS Agency is a county-based agency in

North Carolina with approximately 160 full-time EMTs and 200 full-time paramedics.113

Mecklenburg EMS Agency responds to approximately 146,000 calls for service annually and covers an area that includes more than 1,000,000 residents.113

3.9 Specific Aim 3: Data Collection

Burnout at baseline was assessed using an electronic questionnaire that included the work-related and patient-related subscales of the Copenhagen Burnout Inventory

(Appendix F). A list of e-mail addresses for all EMS professionals employed at

Mecklenburg EMS Agency was obtained. Each e-mail address was assigned a random identification number by Mecklenburg EMS Agency to allow for linkages between survey data and information from occupational records maintained by the agency.

Two weeks prior to administering the baseline questionnaire, a pre-notification slide was presented as part of regularly scheduled mandatory continuing education at the agency. Appendix G displays the informational slide presented to EMS professionals prior to the study launch. Previous research has shown that sponsorship from an authoritative source with whom the target population has a connection is associated with increased propensity for participation.105

An e-mail containing a link to the questionnaire was distributed by e-mail to all

EMS professionals at Mecklenburg EMS agency. The e-mail also contained an explanation of an individual’s rights as a participant and that participation in this study is completely voluntary and that Mecklenburg EMS Agency would not have access to individual responses (Appendix H). Following Dillman’s tailored design method, two reminder e-mails will be sent at seven and 14 days after the initial e-mail invitation.106 As an additional incentive to participate, EMS professionals who responded to the questionnaire were included in a raffle for one of five $100 Amazon gift cards. No personal identifying information was collected and EMS professionals were not able to answer the questionnaire more than once. Survey responses were collected using the electronic survey software SurveyGizmo (Widgix LLC; Boulder, CO).

3.10 Specific Aim 3: Analysis

The objective of the third study was to quantify the association between burnout and three outcomes of interest: 1) turnover, 2) sickness absences, and 3) occupational injury. Only EMS professionals who primarily worked as patient care providers were included in the analysis. The presence of work-related and patient-related burnout was determined using guidelines put forth by the authors of the Copenhagen Burnout

Inventory.114 Descriptive statistics were performed comparing outcome variables by burnout status. Generalized linear models (GLM) were then used to estimate the crude risk ratios for turnover, sickness absence, and injury by burnout status. For each dichotomous outcome, a Bernoulli variance, log link and robust Huber-White standard errors were used.

Potential confounding variables were identified a priori through previous research. Confounding variables for the outcome of occupational injury included age, sex, certification level, call volume, and years of EMS experience. For the workplace withdrawal outcomes of turnover and sickness absence, confounding variables included those previously listed for occupational injury and the additional variable of the number of children in the household. Multivariable generalized linear models were used to estimate risk ratios after controlling for confounding variables.

An analysis comparing characteristics of responders to non-responders was also conducted to evaluate the potential for response bias. Characteristics assessed included age, sex, certification level, turnover, sickness absence, and occupational injury.

Differences were assessed using Chi-square tests for categorical variables and Wilcoxon rank sum tests for continuous, non-normally distributed variables.

Chapter 4. Variation in the Agency-Level Prevalence of Burnout and Associated

Agency Characteristics (Aim 1)

4.1 Abstract

Introduction: Occupational burnout is common among emergency medical services

(EMS) professionals and has been linked to turnover and sickness absence, which negatively impact EMS agencies. Because burnout results from an imbalance between job demands and resources and job characteristics among employees working for the same agency are likely similar, EMS professionals working at the same agency may demonstrate similar levels of burnout. The objectives of this study were to examine variation in the prevalence of burnout at the level of the EMS agency and identify agency characteristics associated with burnout.

Methods: An electronic questionnaire was sent to all EMS professionals who were listed on one or more EMS agency rosters in the state of South Carolina. Work-related and patient-related burnout were measured using the Copenhagen Burnout Inventory.

Analysis was limited to agencies with at least five respondents and a subgroup analysis of agencies with fewer than five respondents was conducted. Agency-level burnout prevalence for each domain was calculated as the number of respondents demonstrating burnout in the domain divided by the total number of respondents affiliated with the agency. Median burnout prevalence was compared across agency characteristics. An abbreviated non-responder questionnaire was conducted to assess for and quantify potential nonresponse bias.

Results: A total of 1,490/8,059 (19%) responses were received with representation from

254/267 (95%) EMS agencies. Agency-level response rates ranged from 4% to 50% with a median of 20% (IQR: 13%-27%). A total of 134 agencies had at least five respondents and were included in the analyses. The agency prevalence of work-related burnout ranged from 0% to 83% with a median of 37% (IQR: 23%-50%). Agency-level patient-related burnout prevalence ranged from 0 to 60% with a median of 8% (IQR: 0%-17%).

Increased annual call volume and increased number of EMS employees were associated with higher median prevalence of both work-related and patient-related burnout. Agency type was associated with patient-related burnout and demonstrated a marginal association with work-related burnout. The highest median prevalence of work-related burnout was seen for governmental (non-fire)-based agencies (41%), followed by private (non- hospital)-based agencies (40%). The highest median prevalence of patient-related burnout was observed for hospital-based agencies (16%) followed by governmental (non-fire)- based agencies (13%). Vehicle count demonstrated a significant association with work- related burnout and a marginal association with patient-related burnout.

Conclusion: The prevalence of burnout varied widely across EMS agencies and burnout prevalence was associated with select agency characteristics. These findings suggest that burnout can be measured and monitored as an agency-level condition.

4.2 Introduction

Responding to over 28 million calls annually, emergency medical services (EMS) professionals routinely experience high physical, mental, and emotional demands while caring for acutely ill or injured patients in the uncontrolled prehospital environment.1

Physically demanding tasks commonly performed as part of EMS work include lifting patients, kneeling for long periods of time, and carrying heavy equipment.38 Complex mental tasks include making critical medical care decisions with incomplete information and performing weight-based medication dose calculations in time-sensitive situations.39

EMS professionals also experience high emotional demands due to frequent exposure to traumatic events, such as the death of a child, or incidents involving multiple casualties.5,6

These intense physical, mental, and emotional demands may place EMS professionals at higher risk for occupational burnout, which is a condition defined as extreme physical and psychological exhaustion perceived by the person as stemming from one’s work.13

Burnout among healthcare professionals has been linked to serious negative consequences for individual providers, their workplace organizations, and the patients served. Providers experiencing burnout may be at increased risk for mental health problems (e.g., depression, anxiety, alcohol abuse) and physical health problems (e.g., sleep disturbances, hypertension, myocardial infarction).17-19,58 Increased absenteeism, reduced job commitment, and turnover among workers experiencing burnout may also negatively impact workplace organizations through increased costs associated with training and recruitment or reduced productivity.20,21 Burnout has further been linked to lower self-reported quality of care provided, decreased patient satisfaction, and increased involvement in patient safety incidents.115

While there have been few investigations of burnout specifically in the prehospital setting, previous research has identified high levels of burnout among select groups of EMS professionals. As early as 1988, Grigsby and McKnew found that paramedics in South Carolina demonstrated higher mean burnout scores compared to

42 other healthcare professionals including emergency room nurses.116 In a 2008 study of volunteer EMS personnel in New York, nearly all participants (92%) scored high in the burnout domain of emotional exhaustion.78 However, this study relied on a convenience sample of EMS professionals and may not be generalizable to a larger EMS provider population. Meanwhile, a large, cross-sectional study of nationally-certified EMS professionals conducted in 2015 estimated that 30% of paramedics and 19% of emergency medical technicians (EMTs) were experiencing work-related burnout.24

Nevertheless, the use of different instruments to measure burnout limits the ability to make meaningful comparisons between existing studies.

Burnout among EMS professionals has been linked to factors that could have a strong, negative impact on the workforce. For example, EMS professionals experiencing work-related burnout demonstrated over a two-fold increase in odds of reporting 10 or more sick days in the past year compared to providers who were not experiencing burnout.24 Similarly, EMS professionals experiencing work-related burnout had a more than three-fold increase in odds of reporting that they intended to leave the profession within the next 12 months.24 High rates of sickness absence and turnover negatively impact EMS agencies as managers may be left struggling to fill empty shifts when providers do not report for duty and there are increased costs associated with onboarding new employees.117

Reducing turnover and maintaining healthy employees is a priority for EMS leaders at the local, state, and national levels.118 The long-term goal of this research is to provide evidence for the development of policies and interventions aimed to prevent burnout among EMS professionals and help those who are suffering from burnout

43 recover. This goal stems from previous research suggesting that occupational burnout negatively impacts the well-being of EMS professionals, EMS agencies, and could ultimately negatively affect the patients served through reduced quality of care and increased likelihood of errors.24,28,115 Despite the negative impact that burnout may have on EMS agencies through increased turnover and sickness absence, previous work has focused on burnout among individual EMS professionals.24,78,79,116 Agency-level burnout prevalence estimates have not been assessed and little is known regarding agency characteristics that are associated with burnout.

4.2.1 Theoretical Framework: Job Demands-Resources Model

The job demands-resources theory was used as the framework for guiding this study. According to this theory, all job characteristics can be classified into two broad categories: demands or resources.83 This theory further defines job demands as physical, social, or organizational aspects of the job that require sustained physical or mental effort or costs, while job resources are physical, social, or organizational aspects of the job that are functional in achieving work goals, reduce job demands or stimulate personal growth, learning, and development. Examples of job demands include workload and time pressure, while job resources include autonomy and performance feedback.89 The job demands-resources theory postulates that burnout is generated as a result of job demands exceeding job resources for extended periods of time, which depletes the employee of mental and physical energy.83 Previous research has supported this theory as high job demands are associated with increased odds of burnout, whereas increased job resources serve to mitigate burnout, particularly in high-stress environments.85,86

Because demands and resources are primarily traits of the job and not of the individual, individuals working for the same EMS agency are likely to experience similar job demands and resources.83 Further, the link between job characteristics and burnout suggests that agencies with higher job demands and lower job resources may have a higher prevalence of burnout than agencies with lower job demands and higher resources.119 Job demands and resources vary significantly from one EMS agency to another. Further, these variations in demands and resources may be associated with certain agency characteristics. For example, a salary survey of EMS professionals conducted in 2015 found that EMTs working for public municipal-based EMS agencies made an average of $13,548 more per year than EMTs working for private EMS agencies.120 Thus, based on the job demands-resources framework, we hypothesized:

Hypothesis 1: The prevalence of burnout varies between EMS agencies.

Hypothesis 2: There is an association between EMS agency characteristics and the prevalence of burnout.

4.2.2 Current Study

The current study was a cross-sectional assessment of variation in the prevalence of burnout between EMS agencies located within a single U.S. state. The objectives of this study were to quantify variation in the prevalence of burnout between EMS agencies and evaluate the association between agency characteristics and burnout. Understanding how burnout levels are similar within EMS agencies and identifying variation between agencies will provide insight as to whether burnout is a condition that agency leaders

45 should monitor and will help guide future work to identify strategies to improve employee well-being.

There is no database of all licensed practicing EMS professionals in the U.S. and a listing of all the agencies for which they work. Licensure information is maintained by each state; nevertheless, not all states maintain rosters of all licensed EMS professionals and the agencies with which they are associated. Thus, we sought to identify a defined population where we could target limited resources and maximize the likelihood of internal generalizability. We identified South Carolina as a state that maintains licensure information for all EMS professionals and complete agency employment rosters, allowing for aggregation of responses by EMS agency.

Because burnout occurs at the interface between the individual and the workplace, understanding burnout at the agency-level is critical to gain a better understanding of the burden of this condition and its potential impact.48 Nevertheless, existing studies of burnout have focused exclusively on burnout at the level of the individual EMS provider.24,77-79 This study will help answer questions as to whether burnout levels within an EMS agency are similar and how much variation exists from one EMS agency to another. Results from this investigation will also contribute to the understanding of whether or not specific agency characteristics are associated with higher levels of burnout. An association between agency characteristics and burnout would provide guidance for future research into the causes of occupational burnout that could be addressed at the level of the EMS agency.

4.3 Methods

4.3.1 Study Design, Population, and Setting

This was a cross-sectional evaluation of licensed EMS professionals from the state of South Carolina. We selected EMS professionals in the state of South Carolina as our study population because selecting a random sample of EMS agencies and EMS employees at these agencies would not be feasible. There is no national listing of all EMS agencies or licensed, practicing EMS professionals. Thus, we sought to identify an enumerable population of EMS professionals that could be linked to EMS agencies. In

South Carolina, the Department of Health and Environmental Control’s (DHEC) Bureau of EMS provides and monitors credentials for all EMS personnel, ambulances, and agencies.97 South Carolina credentials three levels of EMS professionals: Emergency

Medical Technician (EMT), Advanced Emergency Medical Technician (AEMT) and

Paramedic.98 Training and education requirements vary by provider level. EMTs generally receive between 150 and 190 hours of initial education and are trained to administer basic, non-invasive interventions to victims of trauma or acute illness.

Meanwhile, initial paramedic courses usually last more than 1,000 hours and providers at this level are able to perform invasive critical procedures including intravenous drug administration.22

All information related to credentials for EMS agencies, ambulances, and personnel is maintained in the South Carolina credentialing information system database.

Each EMS agency is required to maintain an up-to-date roster of all EMS providers. EMS providers may hold an active license without working for an EMS agency (appearing on a roster). In March of 2017, the workforce of EMS professionals that appeared on at least

47 one EMS agency roster in South Carolina consisted of 53% EMTs (n=4,043), 7%

AEMTs (n=530), and 40% paramedics (n=3,002).99 The target population for this study consisted of all EMS professionals licensed in the state of South Carolina who appeared on at least one agency roster in the month preceding the start of the investigation.

4.3.2 Instrument Development

An electronic questionnaire was developed to measure burnout, provider and agency characteristics. Cognitive interviews were conducted with eight practicing EMTs and paramedics from fire-based, private, and municipal EMS agencies from three U.S. states to assess for readability and consistency in interpretation of the newly developed items. The seven-item work-related burnout and six-item patient-related burnout subscales of the Copenhagen Burnout Inventory were included in the survey (Table 1).

EMS provider demographic and work-related characteristics collected through the questionnaire included age, sex, marital status, number of children living in the household, overall self-reported health rating, employment status at main EMS agency, and length of employment at main EMS agency. Participants were not asked to indicate their race or ethnicity for this study since previous research found that these variables were not associated with burnout.24 Appendix A contains the final survey instrument.

4.3.3 Data Collection

One week prior to data collection the Chief of the South Carolina Bureau of EMS sent a pre-notification e-mail to all EMS professionals in the state to generate awareness of the study and encourage participation (Appendix B). The e-mail also contained a flyer briefly explaining the study (Appendix C). Prior work has shown that support from an authoritative response may serve to increase response rate.105

In November of 2017, an e-mail containing an invitation to participate in a cross- sectional electronic questionnaire was sent to all 8,059 licensed EMS professionals in

South Carolina that appeared on one or more agency rosters in October of 2017

(Appendix D). Providers who were listed on a roster with more than one agency received a single invitation to complete the survey and duplicate responses were not permitted.

The initial e-mail invitation contained a link to the survey and an explanation of rights as a participant. No personal identifying information was collected and participants were not advised of the study’s goals or objectives to reduce the risk of selection bias, meaning that individuals with a more vested interest in the study topic would be more likely to participate, which would yield more extreme results than if selection bias were not present.

Several strategies were employed in an effort to increase participation and reduce the potential for response bias. Following the tailored Dillman methodology, reminder e- mails were sent to those who had not yet participated in the questionnaire at seven days and 14 days following the initial invitation.106 As an added incentive to participate, respondents were entered in a raffle to win one of ten Amazon gift cards worth $100 each.

The institutional review board (IRB) at The Ohio State University ceded oversite to the IRB at the American Institutes for Research, which approved this study and granted a waiver of consent. Reponses to the questionnaire were collected via

SurveyGizmo software (Widgix, LLC; Boulder, CO).

4.3.4 Non-Responder Survey

An abbreviated non-responder survey was conducted to assess for differences between those who participated in the full questionnaire versus those who did not. All

EMS professionals who did not respond to the full questionnaire were sent an invitation to participate in a shortened survey. This questionnaire was designed take two to four minutes to complete and contained items from the main questionnaire related to key demographics including sex, certification level, years of EMS experience, employment status at main EMS job. The work-related subscale of the Copenhagen Burnout Inventory was included to evaluate for differences in burnout scores between responders and non- responders. The work-related burnout subscale was selected since previous research has shown that this type of burnout is more common than patient-related burnout. Because a larger proportion of responders and non-responders would be expected to experience this dimension of burnout, selecting this subscale would result in greater power to detect meaningful differences between responders and non-responders.

4.3.5 Measures

4.3.5.1 Dependent Variables

The Copenhagen Burnout Inventory was used to assess for two types of burnout: work-related and patient-related. The work-related burnout subscale consists of seven items scored on a five-point behavioral frequency scale ranging from always/almost always to never/almost never. The patient-related subscale consists of six items and uses the same five-point behavioral frequency scale. Both the work-related and patient-related burnout subscales have shown good reliability (Cronbach’s alpha: 0.89 and 0.91, respectively) among nationally-certified EMS professionals.24 The questionnaire asked

50 participants to consider the past 30 days when answering each item of the subscales. A

30-day time window was chosen to reduce cognitive burden and limit the potential for recall bias by choosing a period that is recent enough to simplify recall, yet wide enough to capture more than one work week even for EMS professionals who work rotating shifts.

4.3.5.2 Independent Variables

All information related to EMS agency characteristics was obtained from the

South Carolina credentialing information system. A total of seven EMS agency characteristics were evaluated for a relationship with the prevalence of burnout:

1) Service level. The agency service level describes the highest level of care that

the agency is authorized to provide.98 Categories of service level included first

responder, EMT-basic, EMT-intermediate, EMT-paramedic, and nurse. The level

of care and procedures performed differ by service level. For example, agencies

certified at the EMT-basic level perform non-invasive basic life support (BLS)

interventions such as airway positioning and automatic external defibrillation.

Meanwhile, paramedic level services provide advanced life support (ALS)

interventions including IV therapy and endotracheal intubation.98 Because

agencies providing advanced levels of care may experience greater job demands

through contact with critical patients and performance of time-sensitive invasive

procedures, we hypothesized that EMS agencies providing advanced care would

demonstrate higher levels of burnout compared to agencies providing basic care

alone. For analysis, service level was dichotomized to agencies providing basic

life support services only (first responder and EMT-basic) and those that provided

51 a combination of advanced life support and basic life support services (EMT- intermediate, EMT paramedic, and nurse).

2) Agency type. Agency type describes the organizational structure from which

EMS services are delivered.121 Types of EMS agencies in South Carolina include governmental (non-fire), private (non-hospital), fire department, hospital, and community non-profit.99 Job resources, such as pay and benefits, may vary significantly by EMS agency type. For example, fire-based services are traditionally associated with better pay and benefits and have union representation.122 Meanwhile, EMS professionals working for private agencies earn lower salaries on average compared to those working for public agencies.120

We hypothesized that the reduced job resources typically available at private agencies may result in higher rates of burnout at these agencies compared to other types of agencies. An analysis of individual EMS providers lends support for this hypothesis as those working for private agencies demonstrated 57% greater odds of work-related burnout compared to those working for fire-based agencies.24

3) Primary service. The primary service refers to the principal service provided by the agency.121 EMS agency service types included 911 with transport capability, 911 without transport capability, air medical, medical transport

(convalescent), non-emergent transport, and specialty care transport. For analysis, service type was collapsed into meaningful categories of emergent response (911 with transport capability, 911 without transport capability, and air medical) and non-emergent response (medical transport [convalescent], non-emergent transport, or specialty care transport). We hypothesized that agencies providing

52 emergent response would demonstrate higher levels of burnout since EMS professionals may encounter greater physical, mental, and emotional job demands associated with providing emergency treatment in the unpredictable prehospital setting compared to scheduled transports commonly performed by agencies primarily providing non-emergent services.

4) Community size. The Centers for Medicare and Medicaid Services (CMS) define three classifications of community size for reimbursement practices based on the metropolitan statistical areas definitions established by the office of management and budget: urban, rural, and super rural.123 For analysis, rural and super rural were included as a single group due to the small number of super rural agencies (N=2). Urban EMS agencies likely experience higher job demands due to increased call volumes.124 Meanwhile, rural agencies are more likely to employee volunteers who choose to donate their time to providing prehospital care and may be less prone to burnout.125 We hypothesized that EMS agencies located in urban settings would demonstrate higher prevalence of burnout compared to EMS agencies in rural settings.

5) Annual call volume. Agency call volume refers to the number of responses the agency made within a calendar year. For analysis, 2016 agency call volume was dichotomized to agencies that responded to 2,500 or more calls versus agencies that responded to fewer than 2,500 calls based on prior work comparing safety culture across EMS agencies.126 Because call volume represents a job demand, we hypothesized that agencies with greater call volumes and thus greater job

53 demands would demonstrate greater prevalence of burnout compared to agencies that responded to fewer calls.

6) Number of EMS employees. The number of EMS employees refers to the number of licensed EMS professionals listed on the agency roster. For analysis, the number of EMS employees was grouped into categories following previous research among EMS agencies (5 to 20 employees; 21 to 50 employees; 51 to 100 employees; and more than 100 employees).126 In a survey of safety culture, EMS agencies with a larger number of employees demonstrated lower mean scores in perceptions of working conditions.126 Because poorer working conditions may be associated with increased demands and decreased resources, we hypothesized that agencies with more employees would face greater job demands and have higher levels of burnout.

7) Vehicle count. Vehicle count refers to the number of registered ambulances the

EMS agency maintains. Vehicle count is an indicator of how many provider crews the EMS agency could have work at once. Agencies with a greater number of vehicles likely respond to more calls or cover a larger geographic area, implying greater job demands than agencies with fewer vehicles. To compare burnout prevalence by agency vehicle count, this variable was dichotomized to those agencies that had more than the analysis population median vehicle count versus agencies with fewer than the median vehicle count. We chose to create categories representing high and low vehicle counts rather than treat the variable as continuous since we did not expect the effect of vehicle count to necessarily be linear. In the absence of previous work examining the effects of vehicle count, we

chose to dichotomize at the population median vehicle count as a way to separate

agencies with a small number of vehicles to agencies with larger vehicle counts.

We hypothesized that agencies with greater than the median count of vehicles

would demonstrate higher levels of burnout than agencies with fewer than the

median count of vehicles.

While variables four through seven may all be associated with an agency’s size, these measures capture unique characteristics of EMS work and may demonstrate different relationships with occupational burnout. The Spearman’s correlation coefficients between community size, call volume, number of EMS employees, and vehicle count ranged from 0.07 (number of EMS employees with community size) to

0.71 (call volume with agency vehicle count). While 0.71 represents a strong correlation, call volume captures the demand for emergency services, while vehicle count represents a measure of the maximum number of crews that could respond to meet this demand at one time.

4.3.6 Data Analysis

Inclusion criteria consisted of currently practicing EMS professionals certified at the EMT, AEMT, or paramedic levels who provided patient care in the past 30 days.

Emergency medical responders were excluded since South Carolina does not license this level of EMS professional and providers certified at this level often practice in non- traditional settings, not performing EMS work as their primary occupation.

The reliability of the Copenhagen Burnout Inventory work-related and patient- related subscales was assessed using Cronbach’s alpha, with a value of 0.70 or higher indicating adequate reliability. Correlation between the work-related and patient-related

55 subscales was assessed using Spearman’s rank-order correlation coefficient since burnout scores are not expected to be normally distributed based on previous research in this population.24 Continuous and dichotomous measures of work-related and patient-related burnout were calculated following guidelines from the authors of the Copenhagen

Burnout Inventory.114 Responses to each item were assigned the following values: always/almost always=100, often=75, sometimes=50, seldom=25, and never/almost never=0. Then, a composite mean score was calculated for each subscale. Composite scores were not calculated for respondents who answered fewer than three items of a subscale. Following recommendations from authors of the tool, mean composite scores were then dichotomized to those classified as demonstrating burnout (50 or more points) and those who did not demonstrate burnout (less than 50 points) in each domain to facilitate comparisons with previous work.24,114

The prevalence of burnout at the agency level was calculated as the proportion of providers demonstrating burnout over the total number of providers that responded from each agency. Providers were counted with each agency with which they were listed on a roster since burnout is a stable condition and a provider experiencing burnout at one job will likely continue to experience burnout at any other job. In order to provide more stable estimates, analysis was limited to agencies with at least five respondents. A subgroup analysis was conducted for agencies with fewer than five respondents to assess for potential bias introduced as a result of excluding these agencies.

Comparative statistics were calculated to assess for differences in the median prevalence of burnout by agency characteristics. The median prevalence of each type of burnout was compared using Wilcoxon Rank Sum tests for dichotomous variables and

Kruskal Wallis tests for variables with three or more levels. All analyses were carried out using STATA IC version 12.1 (StataCorp LP; College Station, TX).

4.4 Results

4.4.1 EMS Professional Characteristics

A total of 1,490/8,059 (18.5%) responses were received and 1,271 (85.3%) EMS professionals met inclusion criteria. Figure 5 displays the number of EMS professionals excluded from the analyses and rationale for exclusions. Table 3 displays characteristics of the respondents included in the analysis population. The majority of EMS professionals that participated were male (73.9%), which reflects the overall gender composition of the national EMS workforce.127 Most respondents were certified at the paramedic (58.0%) or EMT (36.0%) level. Over one-third (37.7%) had more than 15 years of experience in EMS, while 18.4% had worked in EMS for less than five years.

Over one-third of respondents (35.8%) worked for two or more EMS agencies. The majority of respondents reported working full time (86.2%) at their main EMS agency and 39.8% had worked at their main EMS agency between 3 and 10 years. Most respondents (88.6%) rated their overall health as good, very good, or excellent.

Figure 5. Inclusion of Respondents for Analysis

Table 3. Descriptive Characteristics of EMS Providers (N=1,271) n % Sex Female 327 26.1 Male 924 73.9 Age Range 19-75 Median (IQR) 40 (31-49) Years of EMS Experience Less than 5 years 233 18.4 5 to 15 years 555 43.9 More than 15 years 477 37.7 Certification Level EMT 455 36.0 AEMT/EMT-I 76 6.0 Paramedic 734 58.0 Number of EMS Agencies 1 816 64.2 2 or more 455 35.8 Employment Status at Main EMS Agency Full-time 1,086 86.2 Part-time 174 13.8 Length of Employment at Main EMS Agency Less than 3 years 419 33.2 3 to 10 years 502 39.8 More than 10 years 342 27.1 Call Volume Past 30 Days (All Agencies) 0 315 24.8 1-10 254 20.0 11-50 397 31.2 51-100 214 16.8 >100 91 7.2 Marital Status Married 795 63.2 Divorced/Widowed/Separated 204 16.2 Never Married 176 14.0 Member of an Unmarried Couple 83 6.6 Number of Children in Household None 589 47.0 1 293 23.4 2 244 19.5 3 or more 128 10.2 Overall Health Excellent 145 11.5 Very Good 469 37.1 Good 506 40.0 Fair/Poor 144 11.4

4.4.2 EMS Agency Characteristics

There were 267 EMS agencies registered in South Carolina at the time of this study. Responses were received from EMS professionals listed on rosters for 254/267 agencies (95.1%). Agency level response rates ranged from 3.6% to 50.0% with a median of 19.8% (IQR: 13.0%-27.4%) and the number of respondents per agency ranged from 1 to 96 with a median of 5 (IRQ: 2-11). A total of 52.8% (134/254) of agencies had five or more respondents.

Overall, the most common agency service level was EMT-Paramedic at 50.0% followed by EMT-Basic (38.6%). The primary service provided by the largest proportion of agencies was 911 with transport capability (41.3%). Annual call volume in 2016 ranged from 0 to 81,077 calls with a median of 1,230 calls (IQR: 40-5,722). The number of EMS employees per agency roster ranged from 3 to 457 with a median of 27.5 (IQR:

13-53). Over one-third (39.0%) of agencies employed between 1 and 20 EMS professionals and 8.7% employed over 100 EMS professionals. The majority of agencies were based in urban communities (71.3%) (See Table 4).

Comparisons of EMS agencies by the number of respondents revealed differences between agencies with five or more respondents and agencies with between one and four respondents. More of the agencies with between one and four respondents operated at the

EMT-Basic service level compared to agencies with five or more respondents (61.7% vs

17.9%). A larger proportion of agencies with between one and four respondents were community (non-profit) compared to agencies with five or more respondents (40.8% vs

29.1%). Fewer agencies with one to four respondents provided 911 services with transport capability compared to agencies with five or more respondents (26.7% vs

54.5%). The median agency vehicle count among agencies with one to four respondents was lower compared to that among agencies with five or more respondents (3 vs 9.5).

The median 2016 call volume was also lower among agencies with one to four respondents (64.5 calls) compared to agencies with five or more respondents (4,342). A greater proportion of agencies with between one and four respondents fell into the category of having between 1 and 20 EMS employees compared to agencies with five or more respondents (72.5% vs 9.0%). There was no difference in agency community size by number of respondents (Table 4).

Table 4. Descriptive Characteristics of EMS Agencies by Number of Respondents All Agencies with Agencies with p-value Agencies ≥ 5 1-4 Respondents Respondents N=254 N=134 N=120 n (%) n (%) n (%) Agency Service Level <0.01a First Responder 2 (0.8%) 0 (0.0%) 2 (1.7%) EMT-Basic 98 (38.6%) 24 (17.9%) 74 (61.7%) EMT-Intermediate 13 (5.1%) 4 (3.0%) 9 (7.5%) EMT-Paramedic 127 (50.0%) 100 (74.6%) 27 (22.5%) Nurse 14 (5.5%) 6 (4.5%) 8 (6.7%) Agency Type <0.01a Governmental, Non-Fire 36 (14.2%) 24 (17.9%) 24 (20.0%) Private, Non-Hospital 88 (34.6%) 24 (17.9%) 35 (29.2%) Fire Department 59 (23.2%) 32 (23.9%) 4 (3.3%) Hospital 23 (9.1%) 15 (11.2%) 8 (6.7%) Community, Non-Profit 48 (18.9%) 39 (29.1%) 49 (40.8%) Primary Service <0.01a 911 with Transport 105 (41.3%) 73 (54.5%) 32 (26.7%) 911 without Transport 59 (23.2%) 16 (11.9%) 43 (35.8%) Air Medical 15 (5.9%) 4 (3.0%) 11 (9.2%) Medical Transport 2 (0.8%) 1 (0.8%) 1 (0.8%) Non-Emergent Transport 65 (25.6%) 35 (26.1%) 30 (25.0%) Specialty Care Transport 8 (3.2%) 5 (3.7%) 3 (2.5%) Community Size 0.86a Urban 176 (71.3%) 92 (70.8%) 84 (71.8%) Rural/Super Rural 71 (28.7%) 38 (29.2%) 33 (28.2%) Agency 2016 Call Volume Range 0-81,077 0-81,077 0-13,461 Median (IQR) 1,230 4,342 64.5 <0.01b (40-5,722) (1,230- (1-935) 10,752) Number of EMS Employees <0.01a 1-20 99 (39%) 12 (9.0%) 87 (72.5%) 21-50 85 (33.5%) 53 (39.6%) 32 (26.7%) 51-100 48 (18.9%) 47 (35.1%) 1 (0.8%) >100 22 (8.7%) 22 (16.4%) 0 (0.0%) Agency Vehicle Count Range 0-91 1-91 0-22 Median (IQR) 6 (2-11) 9.5 (6-17) 3 (2-5.5) <0.01b aChi-square test bWilcoxon rank sum test

4.4.3 Agency-Level Burnout Prevalence

The Copenhagen Burnout Inventory subscales of work-related and patient-related burnout demonstrated good reliability in this population. For work-related burnout

Cronbach’s alpha was 0.90 and interitem correlation ranged from 0.53 to 0.60. For patient-related burnout Cronbach’s alpha was 0.86 and interitem correlation ranged from

0.50 to 0.58. The work-related and patient related burnout subscales demonstrated moderate correlation with a Spearman’s correlation coefficient of 0.60, which suggest that the scales are related, but are not identical. These findings are similar to those found among a cohort of 1,914 Danish employees from seven different human service sector professions where Cronbach’s alpha for work-related burnout was 0.87 for work-related burnout, and 0.85 for patient-related burnout and the correlation between subscales was

0.61.128

For all EMS agencies with at least five respondents, the proportion of providers experiencing work-related burnout ranged from 0%-83% with a median of 37% (IQR:

23%-50%) (Figure 6). A total of 34 agencies (25.4%) had a work-related burnout prevalence of 50% or higher. Approximately half of the agencies (n=65, 48.6%) had a work-related burnout prevalence of at least 25% but less than 50%. Only 35 agencies

(26.1%) had a work-related burnout prevalence of less than 25% (Table 5).

The prevalence of patient-related burnout at the 134 EMS agencies with at least five respondents ranged from 0% to 60% with a median of 8% (IQR: 0%- 17%) (Figure

7). The majority of agencies (n=118, 88.1%) demonstrated a patient-related burnout prevalence below 25%. Only two agencies (1.5%) had a patient-related burnout prevalence of 50% or higher (Table 5).

For agencies with five or more respondents, the median agency-level work-related burnout prevalence did not differ by service level, primary service provided, or community size. There was a marginal association between work-related burnout and agency type (p=0.07). The median prevalence of work-related burnout among governmental (non-fire) agencies was highest at 41%, followed by private (non-hospital) at 40%, and was lowest among community (non-profit) agencies at 29%. Agencies with

2016 annual call volumes of 2,500 or higher also demonstrated a higher median work- related burnout prevalence compared to agencies with fewer than 2,500 calls in 2016

(40% vs 33%, p=0.03). Agencies employing between 5 and 20 EMS providers had a lower median prevalence of burnout (23%) compared to agencies with more employees

(21-50 employees: 40%; 51-100 employees: 33%; >100 employees: 40%, p=0.03) The median prevalence of work-related burnout was higher for agencies with six or more vehicles compared to agencies with five or fewer vehicles (40% vs 25%, p<0.01). (See

Table 6).

For agencies with five or more respondents, the prevalence of patient-related burnout at the agency level did not differ by service level, primary service provided, or community size. There was a marginal association between patient-related burnout and vehicle count with agencies having six or more vehicles demonstrating a higher median burnout in the domain (9% vs 0%, p=0.07). For agency type, the highest prevalence of patient related burnout was seen among hospital-based agencies (16%), followed by governmental, non-fire agencies (13%), and the lowest median prevalence of patient related burnout was found among community (non-profit) agencies (0%, p<0.01).

Agencies with 2016 annual volumes of 2,500 or more had a greater median prevalence of

64 patient-related burnout compared to agencies responder to fewer calls (0% vs 9%, p=0.02). Lastly, the lowest median prevalence of patient-related burnout was seen for agencies with between 5 and 20 employees (0%) and the highest median prevalence of patient-related burnout was seen for agencies employing more than 100 EMS professionals (16%; p<0.01) (Table 6).

Table 7 displays a comparison of agency-level burnout prevalence between agencies with one to four respondents and agencies with five or more respondents. The median prevalence of burnout was similar between agencies with one to four respondents and agencies with five or more respondents (33% vs 37%, p=0.79). Meanwhile, the median prevalence of patient-related burnout was lower among agencies with one to four respondents (0%) compared to agencies with five or more respondents (8%; p<0.01).

Figure 6. Prevalence of Work-Related Burnout among EMS Agencies with at Least Five Respondents

Figure 7. Prevalence of Patient-Related Burnout among EMS Agencies with at Least Five Respondents

Table 5. Categories of Work and Patient-Related Burnout Prevalence for EMS Agencies with at Least Five Respondents (N=134) Proportion of Providers Work-Related Burnout Patient-Related Burnout Experiencing Burnout Number of agencies (%) Number of agencies (%) <25% 35 (26.1%) 118 (88.1%) 25%-49% 65 (48.5%) 14 (10.4%) 50%-74% 29 (21.6%) 2 (1.5%) 75% or more 5 (3.7%) 0 (0.0%)

Table 6. Comparison of Median Prevalence of Work and Patient-Related Burnout by Agency Characteristics for Agencies with at Least Five Respondents (N=134) n Median Work- p-value Median Patient- p-value Related Burnout Related Burnout Prevalence Prevalence (IQR) (IQR) Overall 134 0.37 (0.23-0.50) 0.08 (0.00-0.17) Agency Service Level 0.45a 0.21a BLS-Only 24 0.33 (0.20-0.45) 0.00 (0.00-0.15) ALS-BLS 110 0.39 (0.24-0.50) 0.08 (0.00-0.17) Agency Type 0.07b <0.01*b Governmental, Non-Fire 32 0.41 (0.27-0.52) 0.13 (0.04-0.21) Private, Non-Hospital 39 0.40 (0.25-0.48) 0.06 (0.00-0.14) Fire Department 24 0.33 (0.20-0.50) 0.08 (0.00-0.17) Hospital 15 0.38 (0.18-0.47) 0.16 (0.07-0.25) Community, Non-Profit 24 0.29 (0.18-0.40) 0.00 (0.00-0.11) Primary Service 0.12a 0.64a Emergent 93 0.33 (0.20-0.46) 0.08 (0.00-0.17) Non-Emergent 41 0.40 (0.27-0.50) 0.11 (0.00-0.17) Community Size 0.33a 0.33a Urban 92 0.40 (0.25-0.48) 0.09 (0.00-0.19) Rural 38 0.30 (0.20-0.50) 0.07 (0.00-0.14) Agency 2016 Call Volume 0.03*a 0.02*a <2,500 calls 46 0.33 (0.17-0.43) 0.00 (0.00-0.14) 2,500 or more calls 87 0.40 (0.25-0.50) 0.09 (0.00-0.20) Number of EMS 0.03*a <0.01*a Employees 5-20 12 0.23 (0.17-0.33) 0.00 (0.00-0.00) 21-50 53 0.40 (0.27-0.50) 0.00 (0.00-0.20) 51-100 47 0.33 (0.18-0.44) 0.08 (0.00-0.13) >100 22 0.40 (0.33-0.48) 0.16 (0.08-0.20) Agency Vehicle Count <0.01*a 0.07a Less than 6 vehicles 31 0.25 (0.17-0.40) 0.00 (0.00-0.17) 6 or more vehicles 103 0.40 (0.25-0.50) 0.09 (0.00-0.18) aWilcoxon rank sum test bKruskal-Wallis test *p<0.05

Table 7. Comparison of Agency-level Burnout Prevalence by Number of Respondents All Agencies Agencies with Agencies with p-value ≥ 5 Respondents 1-4 Respondents N=254 N=134 N=120 Work-Related 0.79 Burnout Prevalence Range 0%-100% 0%-83% 0%-100% Median (IQR) 35% (13%-50%) 37% (23%-50%) 33% (0%-50%) Patient-Related <0.01 Burnout Prevalence Range 0%-100% 0%-60% 0%-100% Median (IQR) 0% (0%-16%) 8% (0%-17%) 0% (0%-0%)

4.4.4 Non-responder Survey Results

A total of 223 responses to the abbreviated non-responder survey were received, resulting in greater than 80% power to detect a clinically meaningful difference of 10% in prevalence of work-related burnout between responders and non-responders who completed the survey. There were no differences in the proportion of responders experiencing work-related burnout compared to non-responders (p=0.11). Responders and non-responders did not differ significantly in terms of sex, currently practicing in

EMS, employment status, or years of EMS experience. The distribution of EMS certification levels differed between responders and non-responders. A larger proportion of paramedics responded to the full questionnaire (57.5% vs. 45.0%, Bonferroni-adjusted p-value <0.01). (Table 8).

Table 8. Comparison of Full Survey and Non-Responder Survey Participant Characteristics Full Survey Non-Responder p-value Participant Survey (N=1,490) Participant (N=223) Sex 0.60 Female 26.6 (391) 28.3 (63) Male 73.4 (1,081) 71.8 (160) Currently Working in EMS 0.77 Yes 94.2 (1,401) 93.7 (209) No 5.8 (86) 6.3 (14) Employment Status at Main EMS 0.74 Agency Full-time 15.6 (215) 14.6 (30) Part-time 84.5 (1,168) 85.4 (175) Years of EMS Experience 0.95 Less than 5 years 17.8 (250) 18.6 (39) 5 to 15 years 42.4 (596) 42.4 (89) More than 15 years 39.9 (561) 39.1 (82) Certification Level <0.01 EMT 36.6 (502) 45.5 (91) AEMT/EMT-I 5.8 (80) 9.5 (19) Paramedic 57.5 (788) 45.0 (90) Work-related Burnout 0.11 Yes 63.1 (864) 57.4 (117) No 36.9 (505) 42.7 (87)

4.5 Discussion

This study identified wide variation in the prevalence of burnout across EMS agencies located within a single state. The variation in work-related burnout was most pronounced, while the levels of patient-related burnout varied less between agencies, given the lower overall prevalence of this type of burnout. Further, an association was observed between the prevalence of burnout and agency characteristics, including the type of EMS agency, annual call volume, and the number of EMS professionals employed. The results from this study suggest that burnout is related to conditions at the

EMS agency.

Overall, work-related burnout was more prevalent than patient-related burnout.

This finding is supported by previous work among nationally-certified EMS professionals demonstrating that work-related burnout was more common than patient-related burnout at the individual level.24 For example, a large study of nationally-certified EMS professionals estimated that 30% of paramedics experienced work-related burnout compared to just 15% who experienced patient-related burnout. While work-related and patient-related burnout represent two distinct domains, there is a paucity of research exploring why patient-related burnout is less common.13 The stressors that lead to work- related versus patient-related burnout likely differ and could explain why the observed prevalence of these two types of burnout was different. In a review of 16 studies, job- related stressors such as workload and time pressure correlated more strongly with the emotional exhaustion component of burnout than patient-related stressors, such as interaction with difficult clients or frequency of interaction with terminally ill patients.48

It is also possible that patient-related burnout represents a more severe form of burnout.

In a study of 46 medical residents, patient-related burnout was associated with poorer general health and greater mood disturbance compared to job-related burnout.129

In this study, the median prevalence of work-related and patient-related burnout differed by select agency characteristics. Annual call volume and number of EMS employees demonstrated a statistically significant association with both work-related and patient-related burnout. Higher agency call volumes were associated with higher median burnout prevalence, which is consistent with previous research at the individual level.24

The concordance between these findings was expected as individuals working for agencies with higher call volumes are likely to have higher individual call volume loads

70 compared to their counterparts at agencies responding to fewer calls. Agencies within the smallest category of employee count (5 to 20 employees) demonstrated a lower median prevalence of burnout compared to agencies within the higher categories of employee count for both work-related and patient-related burnout. Higher call volumes and a greater number of employees are likely proxies for larger agencies that may face increased job demands. Given that increased job demands are associated with increased burnout, the higher levels of burnout observed at these agencies is consistent with the job demands-resources theory used to guide this work.

Agency type demonstrated a statistically significant association with patient- related burnout, and a marginally significant association with work-related burnout. For both types of burnout, agencies classified as governmental (non-fire) demonstrated one of the highest proportions of burnout, while community (non-profit) agencies had the lowest median burnout prevalence. Whereas private (non-hospital) agencies demonstrated one of the highest estimates of work-related burnout, this agency type demonstrated one of the lowest estimates of patient-related burnout. These findings are partially supported by previous work among nationally-certified EMS professionals that identified higher odds of work-related burnout for individuals working at private agencies compared to those at fire-based agencies.24 Nevertheless, the study of nationally-certified professionals only compared EMS professionals working for fire-based agencies with those working for private agencies. All other types of agencies were grouped together in an “other” category, which precludes the comparison of findings for other public agency types including governmental (non-fire) and community (non-profit).

4.5.1 Job Demands-Resources Model

The job demands-resources model states that burnout arises due to demands exceeding resources at a job for an extended period of time. We hypothesized that because job demands and resources vary between agencies, the prevalence of burnout would also vary at the agency level. We found support for this hypothesis as the prevalence of burnout varied from 0% to 83% for work-related burnout and from 0% to

60% for patient-related burnout.

We further hypothesized that agency characteristics would be associated with the prevalence of burnout. Specifically, we hypothesized that agency characteristics associated with higher job demands or lower job resources would be associated with higher levels of burnout. We found support for this hypothesis as annual call volume, agency type, number of EMS employees, and vehicle count were all associated with one or more forms of burnout. Agency type is a variable that is likely to be associated with the job demands and resources available. A national salary survey showed that public agencies (e.g., fire-based) on average earn higher wages than those at private agencies.120

Given that salary is a job resource, and lower job resources are associated with increased job demands, the finding that private agencies demonstrated a high median prevalence of burnout is in line with the job demands-resources theory. Nevertheless, the national salary survey did not analyze the different types of public agencies separately, which makes comparisons with our findings for the other agency types examined in our study difficult.

Meanwhile, agency annual call volume represents an important measure of workload in EMS, which is a job demand. Whereas most studies that have applied the job

72 demands-resources model have assessed job characteristics at the individual level,89 our study looked at agency-level call volume. We found that agencies that had higher call volumes (higher job demands) demonstrated a greater median prevalence of burnout compared to agencies that had lower call volumes, which is consistent with the job demands-resources model whereby increased job demands lead to increased burnout.83

A larger number of EMS employees and vehicles are also likely associated with increased job demands and may be correlated with increased call volumes. Thus, the finding that increased number of EMS employees and increased number of vehicles were associated with increased levels of burnout is supported by the job demands-resources theory.

Meanwhile, agencies capable of providing advanced life support likely face increased job demands as providers must perform more critical and mentally demanding patient care interventions. However, we did not find a statistically significant association between providing advanced life support services and increased burnout. Possibly the decision to limit the analysis to agencies with five or more respondents impacted this finding as BLS agencies tend to be smaller in size and thus may have been more likely to be excluded from the analysis.

Similarly, no relationship was found between community size and burnout. We hypothesized that agencies operating in urban settings would face increased job demands as working in an urban setting is associated with increased call volumes. Nevertheless, it is plausible that agencies operating in urban settings have access to greater job resources, such as higher pay and benefits.120 Rural agencies also tend to employee fewer EMS

73 professionals and may have been more likely to be excluded from the analysis in this study.

Finally, we did not observe an association between the type of service offered and burnout. We hypothesized that agencies providing emergent services would face increased job demands by treating critical patients and would experience higher levels of burnout. Nevertheless, it is possible that the job resources available at emergent services are greater and offset the increased demands.

4.5.2 Limitations

One of the major limitations to this study is the potential for non-response bias, particularly among smaller EMS agencies where a low response rate could have resulted in the exclusion of the agency from the analysis. For example, if an agency employed only 10 EMS professionals, a 20% response rate means that two people responded to the survey, which would not meet the criterion of at least five respondents to be included in the analysis. Agencies that were excluded from the analysis based on too few responses were less likely to offer services at the advanced life support level, be fire-based, offer

911 services with transport capability, or employ more than 20 EMS professionals. The excluded agencies also responded to fewer calls annually and maintained fewer EMS vehicles. Because job demands may be lower at agencies with fewer employees, that respond to fewer calls, and perform care at the basic life support level only, excluding agencies with fewer than five respondents may have biased the overall estimates of median agency burnout prevalence towards higher levels of burnout. Nevertheless, we felt that it was important to exclude agencies with fewer than five respondents since the

74 weight of a single response would induce a lot of variation in the burnout prevalence when there are fewer than five respondents.

The 19% response rate seen in this study was slightly higher than that seen among previous surveys of EMS professionals. A survey of nationally certified EMS professionals related to burnout saw response rate of 11% among EMTs and 14% among paramedics.24 A census survey of nationally-certified EMS professionals had an overall response rate of 10%.107 EMS professionals who responded to the full survey may have been different than those who did not respond. We expect that our estimates are conservative as EMS professionals suffering from burnout may be less likely to participate in a voluntary electronic survey related to the profession. The converse is also possible as providers with a strong interest in burnout may have been more likely to participate to tell their experience. While participation in the abbreviated questionnaire was also low, the non-responder survey provides some evidence that there no major differences in the experience of work-related burnout between responders and non- responders, though the possibility for non-response bias still exists.

Another important limitation to this study is the potential for these findings to not be generalizable to other populations. This evaluation included providers working within a single U.S. state. While various types of EMS agencies operating in urban and rural settings were included, it is possible that EMS providers working in other states may be different and the prevalence of burnout could differ by region due to differences including salaries, environmental conditions, and patient populations. For example, a national salary survey identified variation in pay and benefits between regions of the

U.S., with EMTs working in FEMA Region IX (California, Nevada, and Arizona)

75 earning the highest salaries and those in FEMA Region IV (Kentucky, Tennessee, North

Carolina, South Carolina, Mississippi, Alabama, Georgia, and Florida) earning the lowest salaries.120 When comparing job resources across regions, it would also be necessary to take into account the cost of living for the area. Nevertheless, the aim of this study was not to provide specific estimates of burnout prevalence among EMS agencies in the US, but rather our objectives were to evaluate whether or not the prevalence of burnout varies between agencies and identify associations between agency characteristics and burnout prevalence.

Finally, elements of the analysis strategy selected introduce certain limitations to the interpretation of the results of this study. Continuous variables were categorized into meaningful groups for comparisons of burnout by agency characteristics. While the decision to categorize helps overcome the challenge of potential non-linear relationships with burnout, a limitation is that agencies with similar characteristics (e.g., call volumes), but falling on opposite sides of the cut point are treated as very different when in fact they may not be very distinct. Another limitation to the analysis is that descriptive statistics were used, rather than a modeling approach. As such, there is a potential for confounding of effects between the agency characteristics that were examined.

Nevertheless, the independent descriptive look at each characteristic’s association with burnout was intended to be exploratory in nature and guide future work to understand the underlying reasons for observed associations.

4.5.3 Implications and Future Directions

Most investigations of burnout have cited this condition as an individual problem that is best addressed by targeting the individual experiencing burnout to improve his or her coping mechanisms.130 However, this practice may be akin to blaming the victim and reducing burnout among EMS professionals will likely require a broader multifaceted approach. In this investigation burnout was found to vary widely by EMS agency, suggesting there may be agency-level factors that play a role in the development of this condition. The results of this study suggest that burnout is a condition that can be monitored at the agency level as part of assessing the workplace climate. The findings of this study further imply that the design of interventions aimed to reduce burnout in EMS, should focus on the individual/organizational interface, rather than focusing solely on the individual.

From the results of this study, we are unable to determine whether a high prevalence of burnout at an EMS agency is linked to negative outcomes. Future work is needed to determine whether agencies experiencing high levels of burnout also experience high rates of turnover or sickness absence. Other potential negative outcomes of high agency-level burnout prevalence include poorer patient care or adverse events.

Future work is needed to assess the relationship between high burnout at the agency-level and patient-related outcomes and conversely, whether low agency burnout prevalence is associated with better patient-related outcomes.

The underlying causes of high burnout prevalence at some agencies also warrants further investigation. While this study uncovered some agency-level characteristics that were associated with burnout, study two of this dissertation will explore the role of

77 specific job demands and job resources with burnout. Identifying characteristics associated with burnout will help guide further investigation into the root causes of this condition and ultimately lead to the development of interventions to prevent and reduce the impact of burnout in EMS.

4.6 Conclusions

The prevalence of work-related and patient-related burnout was found to vary substantially between EMS agencies located within a single state. Agency characteristics including call volume and the number of EMS employees were associated with the prevalence of both patient-related and work-related burnout. This study provides evidence for the need to treat burnout as a condition occurring at the individual and organizational interface rather than placing the burden on the coping skills of the individual provider. These findings suggest that burnout is a condition that should be assessed and monitored at the level of the workplace organization. Future work is needed to develop multifaceted interventions that address burnout in EMS at multiple levels.

Chapter 5. The Association of Job Resources and Job Demands with Burnout

among Emergency Medical Services Professionals (Aim 2)

5.1 Abstract

Introduction: The high job demands faced by emergency medical services (EMS) professionals are likely to generate occupational burnout if left unchecked. Burnout is a condition characterized by severe emotional and physical exhaustion that can negatively affect an employee’s well-being and work performance. Little is known regarding the job demands related to increased burnout in EMS and resources that could mitigate the effects of this condition. The objective of this study was to identify specific job characteristics associated with burnout in EMS.

Methods: A cross-sectional analysis of EMS professionals in South Carolina was conducted. An electronic questionnaire was administered to all licensed, practicing EMS professionals in the state. Work-related and patient-related burnout were measured using the Copenhagen Burnout Inventory. Generalized estimating equations were used to estimate odds ratios for the relationship between job demands, job resources, and burnout while accounting for clustering by main EMS agency and controlling for confounding variables. To compare the effects of job demands and resources simultaneously,

79 composite variables categorized into high and low levels or demands and resources were utilized.

Results: There were 1,490 responses (19%) and 1,271 EMS professionals were included in the analysis. No differences were detected between responders and non-responders in terms of work-related burnout; however, emergency medical technician (EMTs) were less likely to respond to the full questionnaire. More paramedics experienced one or more types of burnout compared to emergency medical technicians (EMTs) (43% vs. 33%). Of those experiencing burnout, few experienced patient-related burnout alone (4%). Job demands significantly associated with work and patient-related burnout included time pressure and components of the physical workplace environment. Important job resources included feedback, rewards, job control, participation, supportive environment, and knowledge. Compared to EMS professionals working in settings with low job demands and high job resources, those exposed to high demands and low resources experienced over a nine-fold increase in odds of work-related burnout and over a six-fold increase in odds of patient-related burnout.

Conclusion: Job resources including aspects of a supportive workplace environment and performance feedback may represent cost-effective measures to reduce burnout, particularly when job demands are high and less easy to modify.

5.2 Introduction

Provider wellness is a vital component for the delivery of safe and effective medical care.131 Occupational burnout, a syndrome characterized by severe emotional and physical exhaustion, represents a growing threat to the well-being of healthcare

80 professionals.13 A study involving responses from more than 6,800 physicians from all specialty disciplines selected from the American Medical Association Physician Master

File, a nearly complete listing of all physicians in the U.S., found that the prevalence of burnout among physicians rose by 17% between 2011 and 2014.15 Burnout among healthcare professionals has been linked to serious negative health consequences including sleep disturbances, depression, alcohol abuse, hypertension, and myocardial infarction.17-19 Further, burnout may negatively affect workforce stability as healthcare providers experiencing this condition have a greater likelihood of exiting their professions early.65,132,133 Patients may also suffer negative consequences as providers experiencing burnout are more likely to report reduced quality of care, lower perception of patient safety culture, and involvement in patient safety incidents.27,66,72,134

While many studies have focused on burnout among healthcare professionals in the hospital setting, few investigations have explored this condition among providers working in the prehospital setting. Emergency medical services (EMS) professionals respond to more than 28 million emergency calls annually and provide acute medical care in uncontrolled environments including public venues, highways, and personal residences.1 Providing prehospital care involves high physical demands (e.g., stretcher loading and unloading and carrying heavy equipment up multiple flights of stairs) and high mental demands (e.g., medication administration calculations, interpretation of electrocardiograms).3,38 EMS professionals also face intense emotional demands through frequent encounters with traumatic events, such as the death of a child, or incidents involving multiple casualties, like motor vehicle crashes.5,6 The extreme physical and

81 psychological demands, coupled with the stress and time pressure inherent to emergency care, may place EMS professionals at increased risk for occupational burnout.18,135

As early as 1988, Grigsby and McKnew found that paramedics in South Carolina demonstrated substantially higher burnout scores on average compared to professionals from other healthcare occupations.116 The average burnout score among paramedics was

96 out of a possible 140, compared to 63 among emergency room nurses.116 A 2015 study analyzing responses from more than 2,000 nationally-certified EMS professionals from across the U.S. estimated that 30% of paramedics and 19% of emergency medical technicians (EMTs) experienced work-related burnout.24 Burnout among EMS professionals was also associated with factors that may negatively impact the workforce.

For example, EMS professionals experiencing burnout demonstrated over a two-fold increase in odds of reporting 10 or more sickness absences in the previous year.24

Burnout was also linked to a more than two-fold increase in intention to leave the EMS profession within the next 12 months.24

The antecedents or possible causes of burnout are complex and include biographical characteristics (e.g., age, sex), personality characteristics (e.g., hardiness, coping style), work-related attitudes (e.g., expectations), and work/organizational characteristics (e.g., workload, client contact).48 Biographical characteristics associated with burnout among EMS professionals include certification level, years of EMS experience, education level, and sex. Compared to those certified to provide basic interventions as emergency medical technicians (EMTs), EMS professionals certified to provide more advanced care at the paramedic level were at increased odds of experiencing work and patient-related burnout.24 Compared to EMS professionals with

82 fewer than five years of experience, those with between five and 15 years of experience were at increased odds of experiencing work-related burnout.24 Completing a bachelor’s degree or higher was associated with increased odds of patient-related burnout.24 Males were at increased odds of patient-related burnout compared to females, but sex was not associated with experiencing work-related burnout.24 Nevertheless, these biographical characteristics are not easily modified and are thus not actionable factors for reducing burnout among EMS professionals. Further, these variables focus on the individual workers, while burnout occurs at the interface between the individual and the workplace, suggesting that characteristics of the EMS agency may also play an important role in this condition.48

Few studies have focused on modifiable characteristics that may likely be intervened upon at the agency-level in EMS. In a study of 99 EMS professionals employed at a private Midwestern agency, increased job autonomy was significantly correlated with reduced burnout (r= -0.55).79 A 1988 study of paramedics in South

Carolina found a significant correlation between burnout and perceptions of paperwork load (r=0.27) and negative relations with coworkers (r=0.47).116 While EMS agency type has been linked to burnout, the factors underlying this difference have not been explored.

Compared to EMS professionals working for fire-based agencies, those working at private agencies had 54% increased odds of burnout.24 One plausible explanation for the difference in odds of burnout by agency type is the higher pay and benefits traditionally associated with working for a fire-based agency compared to working for a private agency.136 Nevertheless, there is a paucity of research examining the strength of the association between specific job characteristics with burnout in EMS.

5.2.1 Theoretical Framework: Job Demands-Resources Model

This research is guided by the job demands-resources model, which postulates that job characteristics have a strong impact on occupational burnout. Specifically, this model characterizes job characteristics into two broad classes. First, are aspects of the job that involve physical or mental effort (job demands).83 Second, are those aspects of the job that facilitate achievement of work goals, or stimulate personal growth (job resources).83 According to this theory, burnout occurs as a result of job demands exceeding job resources for a prolonged period of time.

The job demands-resources model was selected over other models of work stress and burnout due to its flexibility to evaluate the impact of a wide range of job characteristics, rather than specifying a priori which job characteristics are most important.83 For example, the demand-control model posits that burnout results from high job demands and low job control.88 In the job demands-resources model, job control or autonomy is one resource that may be protective against burnout; however, the job demands-resources model acknowledges that other resources may play an important role and the resources that are most important can vary from occupation to occupation.119 The flexibility to evaluate a variety job characteristics was deemed important for this study, as

EMS represents a unique healthcare setting where job demands and resources differ substantially from hospital-based healthcare professions.

While the specific job demands and resources that are important in generating burnout may vary from occupation to occupation, in general, job demands are associated with increased burnout and job resources are associated with reduced burnout.83,89 For this study, we selected specific job demands and resources based on existing literature

84 and discussions with EMS subject-matter experts including providers and medical directors. We then evaluated the relationship between each job demand and resource with burnout. Figure 8 displays the model used to guide this study. We hypothesized:

Hypothesis 1: Job demands will be associated with greater odds of burnout in

EMS.

Hypothesis 2: Job resources will be associated with reduced odds of burnout in

EMS.

Figure 8. The Relationship between Job Demands, Job Resources, and Burnout

5.2.2 Current Study

The current study was a cross-sectional evaluation based on responses to an electronic questionnaire. The objective of this study was to identify job demands and resources associated with work-related and patient-related burnout among EMS professionals. The questionnaire was administered to all EMS professionals licensed and working in the state of South Carolina. A major challenge to examining burnout and associated job-related factors is the lack of a registry of all licensed, practicing EMS

85 professionals and the agencies with which they are affiliated on the national level. Thus, we sought to identify a defined population where EMS professionals could be linked to the agencies where they work. This research was conducted among EMS professionals licensed in the state of South Carolina since personnel information is maintained by the state Bureau of EMS. Using this study population allows for examination of job characteristics and burnout across a wide range of agency types (fire-based, hospital- based, private, etc.) and practice settings (urban, rural).99 The personnel rosters maintained by the SC Bureau of EMS permit accounting for clustering effects at the agency level. Previous research has assessed burnout at the individual level and has not taken into account the clustering effect of EMS agency.24

We hypothesized that job demands would demonstrate a direct relationship with burnout, whereby increased demands are associated with increased odds of burnout.

Identifying the specific job demands that are associated with burnout in EMS is important to be able to design interventions aimed to reduce these demands and in turn, burnout.137

Contrarily, we hypothesized that job resources would demonstrate and inverse relationship with burnout, and that increased job resources would be linked to decreased odds of burnout. Thus, finding specific job resources that impact burnout may be helpful to increase resources, particularly when job demands are high and cannot be modified

(e.g., call volume).85

The long-term goal of this research is to improve the well-being of EMS professionals by providing scientific support for key stakeholders at the federal, state, and local levels to develop policies and interventions that will prevent burnout among EMS professionals and help those who are experiencing burnout recover. Identifying

86 modifiable job characteristics associated with burnout in EMS will provide guidance for where to effectively target future interventions aimed to prevent and reduce burnout. The focus on specific, modifiable job characteristics represents a novel aspect of this work.

Previous work has focused primarily on individual biographical characteristics and non- modifiable agency-level descriptors (e.g., agency type). The job characteristics assessed in this study are likely to represent conditions that can be modified at the agency level, rather than by targeting individuals to modify their behavior. By identifying characteristics that can be intervened upon at the agency level, future interventions targeting these variables are likely to affect a greater number of providers than interventions aimed to help individual EMS professionals manage and cope with job stress.

5.3 Methods

5.3.1 Study Design, Population, and Setting

This was a cross-sectional analysis of data obtained via an electronic survey of

EMS professionals licensed to practice in the state of South Carolina. In the absence of a national registry of every licensed EMS professional and the agencies for which they work, we sought to identify a defined population to first improve the likelihood of internal validity. In addition to maintaining a registry of all licensed EMS professionals, the South Carolina Bureau of EMS requires EMS agencies to maintain a list of active employees (roster) through the electronic credentialing information system. In 2016, there were approximately 7,250 licensed EMS professionals and 200 EMS agencies registered with the state.99 The target population for this study included all EMS professionals licensed to practice in South Carolina who appeared on at least one agency

87 roster in the month prior to the study launch. This study population encompasses EMS professionals working for a variety of agency types (fire-based, governmental, hospital- based, private, and community not-for-profit) and practicing in different settings from urban to rural.99

5.3.2 Instrument Development

Using categories of job demands and resources based on work by Demerouti et al.,83 a questionnaire was developed to assess the relationships between job characteristics and burnout in the EMS setting. A total of five categories of job demands were evaluated: 1) physical workload; 2) time pressure; 3) patient contact; 4) physical environment; 5) shift work.

1) Physical workload. This variable refers to tasks that require the investment of

physical energies. High workload has been associated with higher levels of

burnout.138 In the prehospital setting, a measure of physical workload is the

number of calls to which an EMS professional responds. We hypothesized that

greater workload would be associated with higher odds of burnout.

2) Time pressure. This variable refers to the perception that there is not enough

time to complete work tasks. High time pressure is associated with increased

burnout.139 Providing emergency care inherently involves time pressure to provide

lifesaving care for time-sensitive conditions such as myocardial infarction or

stroke. Nevertheless, EMS professionals may have to hurry between responses to

complete tasks such as documentation and cleaning of the ambulance, which may

be perceived as an important job demand.103 We hypothesized that increased

perception of time pressure would be associated with increased odds of burnout.

3) Patient contact. Interactions with more demanding clients or patients has been linked to higher levels of burnout.140 In EMS, encountering patients in emergent settings may imply higher physical and cognitive demands compared to working with patients in non-emergent settings. We hypothesized that EMS professionals working in emergent settings would demonstrate higher odds of burnout compared to those working in non-emergent settings.

4) Physical environment. This variable refers to the physical working conditions or lack of working conditions. Poor or uncomfortable working environment conditions have been associated with increased burnout.139 The absence of certain physical aspects of the work environment may represent important job demands in EMS. Characteristics of the physical environment evaluated were dedicated places to sleep, shower, eat/prepare food, store belongings, exercise, and relax.

We hypothesized that a lack of each of these aspects of physical environment would be associated with increased odds of burnout. Posting in an emergency vehicle is a practice used by EMS agencies to position ambulances strategically to improve response times. Nevertheless, being restricted to working from an emergency vehicle for long periods of time without access to the base environment may represent an important job demand in EMS. We hypothesized that posting in an emergency vehicle frequently would be associated with increased odds of burnout.

5) Shift work. This variable refers to a wide variety of working schedules that include hours outside of normal daytime hours.141 Unfavorable shift work schedules have been related to increased burnout.83,142 EMS professionals

89 frequently work long shifts of 12 or 24 hours and encompassing overnight hours.40 We hypothesized that working an increased number of long or overnight shifts would be associated with greater odds of burnout.

A total of six categories of job resources were evaluated:

1) Performance feedback. Lack of appropriate feedback about performance has been linked to reduced burnout.139 Previous work has shown that EMS professionals do not frequently receive feedback regarding the medical care provided from their supervisor or medical director, which could represent an important missing job resource.107 We hypothesized that EMS professionals who received performance feedback would demonstrate reduced odds of burnout.

2) Rewards. Rewards consist of money, benefits, esteem, or career advancement opportunities that are distributed by an employer.87 Increased rewards are associated with reduced levels of burnout.83 Low pay and benefits of EMS professionals compared to healthcare workers in other settings is an important workforce concern.34,118 Pay and benefits vary greatly between EMS agency characteristics and geographic regions.120 We hypothesized that increased pay and access to benefits would be associated with reduced odds of burnout.

3) Job control. Autonomy to decide how to do one’s work has been linked to reduced burnout.83 In EMS, important aspects of job control include over the way medical care is provided as well as control over one’s schedule. We hypothesized that greater job control would be associated with reduced odds of burnout.

4) Participation. Working in a participatory environment has been linked to reduced burnout.83 We hypothesized that EMS professionals who perceived that

their input was valued at their EMS agencies would demonstrate reduced odds of

burnout compared to their counterparts who perceived that their input was not

valued.

5) Supportive environment. Low managerial support has been linked to increased

burnout.90 Other work has suggested that support from co-workers is also

inversely associated with burnout.139,143 We hypothesized that increased support

from supervisors or co-workers would be associated with reduced odds of

burnout.

6) Knowledge. Orientation education and on-the-job training are job resources

that have been associated with reduced burnout.139 Increased educational

opportunities have been associated with reduced burnout. We hypothesized that

adequate orientation and training would be associated with reduced odds of

burnout.

Where possible, items were adapted from instruments that have been previously utilized among EMS professionals including the EMS safety attitudes questionnaire

(SAQ),101 and an EMS safety culture instrument adapted from the Agency for Healthcare

Research and Quality’s Surveys on Patient Safety Culture (SOPS™).103 Table 9 and

Table 10 display the categories of job demands and resources, the specific item or items used to measure each category, sources for each item and newly developed items.

Variables related to EMS provider characteristics and demographics were also collected through the survey including sex, years of EMS experience, and work status (full- time/part-time).

All items developed specifically for this study were cognitively tested with eight practicing EMS professionals from three states that were not part of the study population.

These EMS professionals worked for various agency types including fire-based, private and municipal. Cognitive interviews were conducted to test readability and consistency in interpretation of the items before deploying the survey to the study population.

Participants for the cognitive interviews were selected by purposive sampling to capture views from practicing EMS professionals working for different agency types and practicing in different community sizes.104 Given that the survey was to be administered as a census, EMS professionals from the target population were not selected for cognitive interviewing so that they would not be exposed to the study questions more than once.

Based on feedback from the cognitive interviews, language was modified where appropriate and the survey instrument was finalized. Appendix A contains the complete questionnaire.

Table 9. Sources for Items Related to Job Demands in EMS Job Demands Variable Item Source Category Physical Provider Call Volume N/A Patient Care workload in the Past 30 days Record Data Time Pressure Work Pace EMS personnel have SOPS-based to hurry between runs survey24 because they have too much work to do. Patient Contact Service type: N/A Agency data from Emergent vs. Non- South Carolina Emergent Bureau of EMS Frequency of Posting At your main EMS New item in Emergency Vehicle job, how often do you post in your emergency vehicle while awaiting calls? Physical Base Environment At your main EMS New item Environment agency, do you have a dedicated space to: sleep; shower; eat/prepare food; store belongings; exercise; relax Shifts lasting 24 In the past 4 weeks, New item hours or longer how many shifts have you worked that were 24 hours or longer at your main EMS job? Shift work Overnight shifts In the past 4 weeks, New item how many overnight shifts have you worked at your main EMS job?

Table 10. Sources for Items Related to Job Resources in EMS Job Resources Variable Item Source Category Feedback Performance I receive appropriate EMS SAQ101 feedback (Supervisor) feedback about my performance from my immediate supervisor. Performance I receive appropriate EMS SAQ101 feedback (Medical feedback about my Director) performance from my medical director. Rewards Benefits Which of the New item following benefits do you receive from your main EMS agency? Overtime Pay I depend on overtime New item pay to make ends meet. Job control Autonomy I have freedom to New item decide how I do my work Schedule I have sufficient New item control over my schedule Participation Input EMS personnel input EMS SAQ101 is well-received at my main EMS agency. Supportive Management support The management of EMS SAQ101 Environment this EMS agency supports my daily efforts. Respect from My immediate SOPS-based Supervisor supervisors treat me survey24 with respect. Respect from Co- My co-workers treat SOPS-based workers me with respect. survey24

Knowledge Training Staff get the training SOPS-based they need in this survey24 service. Orientation Staff who are new to SOPS-based this service receive survey24 adequate orientation.

5.3.3 Data Collection

To encourage participation among the target population, one week prior to initiating the study, the Chief of the South Carolina Bureau of EMS sent a prenotification e-mail to all EMS professionals (Appendix B) that contained an attachment with a pre-notification flyer (Appendix C). Previous research suggests that support from an authoritative source can improve response rate.105 In November of 2017, an e-mail invitation was sent to all EMS professionals in South Carolina who were listed on one or more agency rosters with the Bureau of EMS (Appendix D). EMS professionals were not permitted to answer the survey more than once and those listed on more than one agency roster received a single invitation to participate in the study. The e-mail contained a link to the electronic questionnaire as well as an explanation of one’s rights as a participant.

Participation was completely voluntary and had no bearing on an individual’s EMS credential in South Carolina. No personal identifying information was collected. All responses were collected via SurveyGizmo software (Widgix, LLC; Boulder, CO).

Reminder e-mails were sent to EMS professionals who had not participated in the survey at seven and 14 days after the initial invitation. Judicious use of reminder e-mails has been shown to improve response rates.106 To further incentivize participation, respondents were included in a raffle to win one of ten Amazon gift cards worth $100 each. The institutional review board at The Ohio State University ceded oversight to the institutional review board at the American Institutes for Research, which approved this project and granted a waiver of documented consent.

5.3.4 Non-Responder Survey

Previous research among EMS professionals using electronic survey instruments has demonstrated response rates typically ranging from 10 to 20 percent.24,108,144 In an effort to evaluate the potential for non-response bias, an abbreviated non-responder survey was conducted. The non-responder survey was designed to take between two to four minutes to complete and included a small number of items selected from the full survey instrument. Items assessed in the non-responder survey included key provider characteristics such as, sex, certification level, years of EMS experience, and employment status at main EMS job. To assess for potential differences in burnout between responders and non-responders, the work-related burnout subscale of the

Copenhagen Burnout Inventory was also included. The work-related subscale was selected over the patient-related subscale since a greater proportion of EMS professionals demonstrated this type of burnout in a national survey of more than 2,000 providers.24

Given the small number of expected participants to the non-responder survey, achieving the power necessary to detect a meaningful difference in patient-related burnout would be more difficult since fewer providers experience this type of burnout.

5.3.5 Measures

5.2.5.1 Dependent Variables

The Copenhagen Burnout Inventory was used to measure two domains of burnout: work-related and patient-related.13 Work-related burnout is defined as severe emotional and physical exhaustion that an individual attributes to his or her work.13

Patient-related burnout is defined as severe physical and mental exhaustion that an individual attributes to his or her work with patients.13 Burnout was assessed using the

96 work-related and patient-related subscales of the Copenhagen Burnout Inventory. The work-related and patient-related subscales have been used previously among EMS professionals and demonstrated adequate reliability (Cronbach’s alpha 0.89 and 0.91, respectively).24

5.3.5.2 Independent Variables

Independent variables related to job characteristics were classified into two primary groups: job demands or job resources. Categories of job demands were selected based on work by Demerouti et al.83 Job demand categories included 1) physical workload, 2) time pressure, 3) patient contact, 4) physical environment, and 5) shift work.

Job resource categories included 1) performance feedback, 2) rewards, 3) job control, 4) participation, 5) supportive environment, and 6) knowledge. Table 9 and Table 10 in section 5.3.2 of this paper on instrument development display the items used to measure each of these categories and the sources of the items. For categories that included more than one item (e.g., base environment), each item was evaluated separately for a relationship with burnout.

5.3.5.3 Confounding Variables

Confounding variables are those that influence the exposure variable and the outcome variable and may explain all or part of the difference observed between the exposure and the outcome.145 Variables that have the potential to confound the relationship between job demands, job resources, and burnout were identified through a review of the existing literature. Five important confounding variables were identified for this study (Figure 9):

1) Certification level. Providers certified at the EMT level likely experience different job demands and resources compared to providers certified at the advanced life support levels of AEMT and paramedic. EMTs receive approximately 150-190 hours of education and provide basic emergency care and transportation for sick and injured patients.22 AEMT courses typically last between 150-250 hours and EMS professionals certified at this level are able to provide limited advanced emergency medical care.22 Paramedic is the most advanced nationally-recognized EMS provider level and EMS professionals certified at this level can perform advanced emergency medical care.146 Previous research has shown that paramedics are at increased odds of work and patient- related burnout compared to EMTs.24

2) EMS experience. EMS experience may be associated with job characteristics such as control over work schedule in organizations that give priority to shift schedules based on seniority. Further, employees with more tenure may receive greater compensation. Years of EMS experience has been linked to burnout as those with between five to 10 years of experience were at increased odds of burnout compared to those with less than five years in EMS.24

3) Full-time work status. Whether or not an employee has full-time status is likely associated with job resources, such as benefits available at the job including health insurance. Full-time status is also likely to impact burnout as providers who work full-time are likely to respond to more calls and are less likely to have time to recover and avoid burnout.

4) EMS agency type. Agency type may also confound the relationship between job demands, resources and burnout as job characteristics are likely to vary by

EMS agency type. Providers at fire-based agencies are likely to receive better pay and benefits compared to providers at private agencies.136 Further, EMS professionals working for private agencies demonstrated 57% increase in odds of work-related burnout compared to their counterparts at fire-based agencies.24

5) Community size. Finally, community size may play a role in job demands, available job resources and the likelihood of experiencing burnout. Providers working in rural settings may have less access to resources like funding for training and many of these providers work on a volunteer basis.147 Long transport times and other barriers unique to providing healthcare in rural settings may impact burnout differently than practice in an urban setting.148

Figure 9. Confounding Variables for the Relationship between Job Characteristics and Burnout in EMS

5.3.6 Data Analysis

Only providers certified at the EMT, AEMT, or paramedic levels who provided patient care in the 30 days preceding the survey were included in the analyses. Providers indicating that they were practicing at the emergency medical responder (EMR) level were excluded since the state of South Carolina does not license this level and providers who practice at this level often work in non-traditional settings where working as an EMS professional is not their primary responsibility such as at industrial or automotive plants.

EMS professionals who did not provide patient care in the past 30 days were excluded in order to maintain a single population for analysis with work-related and patient-related

100 burnout, since having worked with patients is a requirement for answering the patient- related burnout subscale of the Copenhagen Burnout Inventory.

Internal consistency of the Copenhagen Burnout Inventory for the study population was assessed using Cronbach’s alpha and a value of 0.70 or higher indicating acceptable reliability. Spearman’s rank correlations were used to evaluation the correlation between the work-related and patient-related burnout subscales since burnout scores are likely to follow a non-normal distribution.24 To enhance interpretability of the results, dichotomous variables were created for work-related and patient-related burnout following recommendations from the authors of the Copenhagen Burnout Inventory. First points were assigned for each item response using the following scoring: always/almost always=100, often=75, sometimes=50, seldom=25, and never/almost never=0. Each participant’s responses were added up for each subscale and divided by the total number of items answered in the subscale. Composite scores for burnout subscales were excluded for participants who answered fewer than three items of a subscale. Individuals were categorized as having burnout in the specific domain if the average score was 50 or higher in order to facilitate comparisons with previous work among EMS professionals using this instrument.24,114

The association between each job characteristic and each domain of burnout was assessed using separate generalized estimating equation (GEE) models that accounted for the clustering of the data at the EMS agency level. Providers who worked for more than one EMS agency were asked to indicate their main EMS agency. Main EMS agency was used as the independent cluster since EMS professionals could only have a single main

EMS agency. The use of a marginal modeling approach such as GEE is appropriate when

101 comparisons between clusters are of primary interest.110 We selected GEE because the primary objective of this study was to identify job characteristics associated with each type of burnout while accounting for the clustering of job characteristics among providers working for the same agency. We selected working exchangeable as the correlation structure because this option results in consistent estimates of the coefficients even when the true correlation structure is unknown.110 Given the dichotomous burnout outcome measure, a logit link and Bernoulli variance was used to estimate odds ratios for experiencing burnout. The Huber-White sandwich variance estimate was used because this estimate yields correct estimates of the coefficients even if the variance function or correlation structure are specified incorrectly.110

Univariable models were constructed to assess for crude associations between work-related and patient-related burnout and job characteristics after controlling for the cluster effect of EMS professionals who worked for the same main EMS agency.

Associations between each job characteristic and each domain of burnout were assessed using multivariable models to control for the confounding variables selected a priori based on a directed acyclic graph as described in the 5.3.5.3 Confounding Variables section of this paper (Figure 9).

Next, the presence of job demands and resources were assessed together following an approach similar to that undertaken in the Whitehall II study.112 A composite variables was created for total job demands by adding up response options for each job demand (Table 11). The median job demand score for the analysis population was calculated. EMS professionals were classified as having high job demands if their job demand composite score exceeded the median for the analysis population or low

102 otherwise. Similarly, a composite variable was created for total job resources (Table 12).

EMS professionals were then classified as having either high or low job resources based on the median composite score in the analysis population. Based on these classifications, four quadrants of job characteristics were constructed: 1) low demands/high resources, 2) low demands/ low resources, 3) high demands/ low resources, and 4) high demands/ high resources. The ideal situation of low job demands with high job resources was used as the referent group. GEE models were used to estimate the unadjusted and adjusted odds of each type of burnout were based on job demands and resources exposure status.

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Table 11. Scoring for Job Demands Composite Measure Demand Response Categories Points Assigned Provider call volume past 30 days 0 0 1-10 1 11-50 2 51-100 3 >100 4 Time pressure Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Patient contact Non-emergent 0 Emergent 1 Post in emergency vehicle Never 0 Seldom 1 Sometimes 2 Often 3 Always 4 Work environment does NOT include Sleep 1 a place to: Shower 1 Eat/prepare food 1 Store belongings 1 Exercise 1 Relax 1 Number of shifts ≥24 hours 0 0 1-3 1 4-9 2 10-12 3 More than 12 4 Number of overnight shifts 0 0 1-3 1 4-9 2 10-12 3 More than 12 4 Maximum points possible 26

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Table 12. Scoring for Job Resources Composite Measure Resource Response Categories Points Assigned Feedback from medical director Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Feedback from supervisor Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Has the following benefits: Paid vacation 1 Paid sick leave 1 Health insurance 1 Dental insurance 1 Vision insurance 1 Uniform allowance 1 Paid uniforms 1 Tuition assistance 1 Retirement plan 1 Depends on overtime pay to make ends Strongly disagree 1 meet Slightly disagree 2 Slightly agree 3 Strongly agree 0 Job autonomy Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Control over schedule Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Personnel input is well-received Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Management support Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Respect from supervisor Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Continued

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Table 12. Continued Resource Response Categories Points Assigned Respect from co-workers Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Adequate orientation Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Adequate training Strongly disagree 0 Slightly disagree 1 Slightly agree 2 Strongly agree 3 Maximum points possible 42

5.4 Results

We received responses from 1,490 individuals from the 8,059 eligible EMS professionals (18.5%) who were sent an invitation to complete the survey. After excluding EMS professionals who were not currently practicing in EMS, were certified at the EMR level, and those who did not provide patient care in the past 30 days, a total of

1,271 EMS professionals (85.3% of respondents) were included in the analysis.

Reflective of the EMS workforce, the majority of participants were male

(73.9%).35 Participant age ranged from 19 to 75 years with a median of 39 years (IQR:

31-49). Most were certified at the paramedic level (58.1%) and 43.9% had between five and 15 years of EMS experience. Over one-third worked for two or more EMS organizations (35.8%) and the majority were employed full-time at their main EMS agency (86.2%). Most rated their overall health as good, very good, or excellent (88.5%)

(See Table 13).

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The Copenhagen Burnout Inventory subscales of work-related and patient-related burnout performed adequately in this group of EMS professionals (Cronbach’s alpha:

0.90 and 0.86, respectively). The correlation between scales was 0.60 suggesting that work-related and patient-related burnout are linked, but not identical.

Over one-third of participants were experiencing at least one type of burnout

(39.0%). Of those experiencing burnout, the majority demonstrated work-related burnout only (70.1%). Very few of those experiencing burnout presented with patient-related burnout alone (3.8%). A total of 26.0% of those experiencing burnout were experiencing both work-related and patient-related burnout (Table 14). The prevalence of burnout differed by provider level as 41.0% of paramedics/AEMTs experienced work-related burnout compared to 31.6% of EMTs. For patient-related burnout, 13.6% of paramedics/AEMTs experienced burnout in this domain compared to 8.1% of EMTs.

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Table 13. Characteristics of EMS Professionals Included in the Analysis Population (N=1,271) n % Sex Female 328 26.1 Male 929 73.9 Age Range 19-75 Median (IQR) 39 (31-49) Years of EMS Experience Less than 5 years 234 18.4 5 to 15 years 558 43.9 More than 15 years 479 37.7 Certification Level EMT 456 35.9 AEMT/EMT-I 76 6.0 Paramedic 739 58.1 Number of EMS Agencies 1 816 64.2 2 or more 455 35.8 Employment Status at Main EMS Agency Full-time 1,086 86.2 Part-time 174 13.8 Length of Employment at Main EMS Agency Less than 3 years 420 33.1 3 to 10 years 506 39.9 More than 10 years 343 27.0 Call Volume Past 30 Days (All Agencies) 0 315 24.8 1-10 254 20.0 11-50 397 31.2 51-100 214 16.8 >100 91 7.2 Marital Status Married 799 63.2 Divorced/Widowed/Separated 204 16.1 Never Married 178 14.1 Member of an Unmarried Couple 83 6.6 Number of Children in Household None 590 46.8 1 297 23.6 2 245 19.4 3 or more 128 10.2 Overall Health Excellent 145 11.4 Very Good 472 37.2 Good 507 39.9 Fair/Poor 146 11.5

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Table 14. Burnout Prevalence among EMS Professionals in South Carolina by Type of Burnout Overall Paramedic/AEMT EMT % (n/N) % (n/N) % (n/N) 37.6% 41.0% 31.6% Any work-related burnout (477/1,269) (333/813) (144/456)

11.6% 13.6% 8.1% Any patient-related burnout (148/1,271) (111/815) (37/456) 39.1% 42.8% 32.5% Any burnout (496/1,269) (348/813) (148/456)

70.1% 68.1% 75.0% Work-related burnout only (348/496) (237/348) (111/148)

3.8% 4.3% 2.7% Patient-related burnout only (19/496) (15/348) (4/148)

26.0% 27.6% 22.3% Work and patient-related burnout (129/496) (96/348) (33/148)

5.4.1 Prevalence of Job Demands and Job Resources

The median number of calls responded to in the past 30 days by EMS professionals was 16 with an interquartile range of 1 to 49 calls. Most EMS professionals worked for an agency that primarily provided emergent response (81.8%). Time pressure was a common job demand, as 71.7% of EMS professionals indicated that they had to hurry between calls because they have too much work to do. Meanwhile, fewer than one- third of respondents reported frequently posting in their emergency vehicle (27.8%).

With regards to work environment, few respondents reported the absence of a place to relax (11.6%) or to eat/prepare food (12.7%). Meanwhile, a larger proportion of EMS professionals reported the lack of an area to exercise at work (63.2%). Over half worked at least one 24 hours shift in the past four weeks (58.0%) and most worked at least one overnight shift (71.2%). Table 15 displays the prevalence of each job demand analyzed in this study.

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With regards to job resources, receiving performance feedback from a supervisor

(58.5%) was more common than receiving feedback from a medical director (33.6%).

Paid vacation (83.3%), health insurance (81.9%), dental insurance (80.4%), and paid uniforms (80.8%) were commonly reported benefits. Less commonly reported benefits included tuition assistance (42.1%) and uniform allowance (32.9%). Only about one- third (35.4%) of respondents reported that they did not depend on overtime pay to make ends meet. While perceiving respect from supervisors was common (87.0%), fewer respondents reported receiving support from management (67.1%). Slightly over half of respondents (58.5%) reported adequate orientation for new staff at their main EMS jobs and 67.6% reported that staff at their EMS agency receive adequate training. Table 16 displays the prevalence of each job resource examined in this investigation.

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Table 15. Prevalence of Job Demands among EMS Professionals in South Carolina Variable % (n) Workload Provider Call Volume Past 30 Days Median (IQR) 16 (1-49) Time Pressure Have to hurry between calls (Yes) 71.7% (908) Patient Contact Main EMS Agency Service Type Emergent 81.8% (1,017) Non-Emergent 18.2% (227) Physical Environment Post in emergency vehicle Never/Seldom/Sometimes 72.2% (916) Often/Always 27.8% (353) Work environment does NOT include a place to: Sleep 30.4% (386) Shower 22.1% (281) Eat/prepare food 12.7% (161) Store belongings 26.0% (329) Exercise 63.2% (802) Relax 11.6% (147) Shift work Number of shifts ≥24 hours None 42.0% (529) 1 to 3 9.4% (118) 4 to 9 15.5% (196) 10 to 12 23.5% (297) More than 12 9.6% (121) Number of overnight shifts None 28.8% (364) 1 to 3 9.0% (114) 4 to 9 17.6% (222) 10 to 12 25.9% (327) More than 12 18.7% (237)

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Table 16. Prevalence of Job Resources among EMS Professionals in South Carolina Variable % (n) Performance Feedback Medical Director (Yes) 33.6% (425) Supervisor (Yes) 58.5% (740) Rewards Benefits (Yes) Paid vacation 83.3% (1,059) Paid sick leave 76.7% (972) Health insurance 81.9% (1,039) Dental insurance 80.4% (1,020) Vision insurance 76.4% (970) Uniform allowance 32.9% (416) Paid uniforms 80.8% (1,021) Tuition assistance 42.1% (530) Retirement plan 79.5% (1,005) Depend on overtime pay (No) 35.4% (449) Job Control Job autonomy (Yes) 73.1% (926) Control over schedule (Yes) 55.9% (708) Participation Personnel input is well-received (Yes) 60.4% (764) Supportive Environment Management support (Yes) 67.1% (848) Respect from supervisor (Yes) 87.0% (1,101) Respect from co-workers (Yes) 93.3% (1,178) Knowledge Adequate Orientation (Yes) 58.5% (741) Adequate Training (Yes) 67.6% (856)

5.4.2 Work-Related Burnout and Confounding Variables

For variables that could confound the association between job demands and work- related burnout, certification level, full-time work status, and main EMS agency type demonstrated a significant association with work-related burnout. Compared to EMTs, those practicing at the AEMT or paramedic level had 48% increased odds of work-related burnout (OR: 1.48, 95% CI: 1.17-1.88). EMS professionals working full-time at their main EMS agency had 87% increased odds of experiencing work-related burnout compared to those who worked part-time (OR: 1.87, 95% CI: 1.32-2.66). Compared to

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EMS professionals working for fire-based agencies, those at governmental, non-fire based agencies demonstrated 51% increased odds of work-related burnout (OR: 1.51,

95% CI: 1.01-2.24) (Table 17). All confounding variables were included in the multivariable models regardless of statistical significance since these variables were selected a priori based on existing literature.

Table 17. Odds Ratios for the Association between Confounding Variables and Work- Related Burnout Variable Univariable OR (95% CI) Certification Level EMT Referent AEMT/Paramedic 1.48 (1.17-1.88)* EMS Experience Less than 5 years Referent 5 to 15 years 1.33 (0.93-1.89) More than 15 years 1.19 (0.83-1.71) Work status Part-time Referent Full-time 1.87 (1.32-2.66)* Main EMS Agency Type Fire-based Referent Governmental, non-fire based 1.51 (1.01-2.24)* Hospital-based 1.57 (0.97-2.54) Private, non-hospital based 1.22 (0.81-1.83) Community, non-profit 0.96 (0.53-1.72) Main EMS Agency Community Size Rural Referent Urban 1.05 (0.75-1.47)

5.4.3 Work-Related Burnout and Job Demands

After controlling for the confounding variables listed in Figure 9, adjusted odds ratios showed a significant association between certain job demands and increased odds of burnout. Time pressure was associated with over a four-fold increase in odds of work- related burnout (OR: 4.40, 95% CI: 3.26-5.93). Frequently posting in an emergency vehicle (OR: 2.26, 95% CI: 1.72-2.98) and working more than 12 shifts lasting 24 hours

113 or longer (OR: 2.26, 95% CI: 1.29-3.97) were associated with more than two-fold increases in odds of work-related burnout. With regards to work environment, not having a place to exercise (OR: 2.98, 95% CI: 2.21-4.02) or eat/prepare food (OR: 2.79, 95% CI:

1.82-4.29) were associated with the greatest odds of work-related burnout. Meanwhile, working for an agency that primarily provides non-emergent services was associated with reduced odds of work-related burnout (OR: 0.49, 95% CI: 0.27-0.89). Table 18 displays the unadjusted odds ratios and adjusted odds ratios for job demands and work-related burnout.

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Table 18. Unadjusted and Adjusted Odds Ratios for the Association between Job Demands and Work-Related Burnout Variable Unadjusted OR Adjusted OR (95% CI) (95% CI)a Workload Provider Call Volume Past 30 Days 1.00 (1.00-1.01) 1.00 (1.00-1.00) Time Pressure No Referent Referent Yes 4.66 (3.44-6.31)* 4.40 (3.26-5.93)* Patient Contact Main EMS Agency Service Type Non-Emergent Referent Referent Emergent 0.76 (0.55-1.04) 0.49 (0.27-0.89)* Physical Environment Post in emergency vehicle Never/Seldom/Sometimes Referent Referent Often/Always 2.20 (1.73-2.80)* 2.26 (1.72-2.98)* Work environment does NOT include a place to:b Sleep 1.19 (0.92-1.53) 1.14 (0.84-1.54) Shower 1.91 (1.45-2.51)* 2.40 (1.72-3.34)* Eat/prepare food 2.50 (1.65-3.79)* 2.79 (1.82-4.29)* Store belongings 1.63 (1.27-2.08)* 1.75 (1.33-2.28)* Exercise 2.48 (1.93-3.20)* 2.98 (2.21-4.02)* Relax 2.29 (1.59-3.32)* 2.46 (1.64-3.69)* Shift work Number of shifts ≥24 hours None Referent Referent 1 to 3 1.33 (0.85-2.08) 1.25 (0.75-2.08) 4 to 9 0.97 (0.62-1.52) 0.96 (0.60-1.53) 10 to 12 1.44 (1.01-2.08)* 1.47 (0.98-2.20) More than 12 2.06 (1.22-3.47)* 2.26 (1.29-3.97)* Number of overnight shifts None Referent Referent 1 to 3 1.11 (0.70-1.76) 1.13 (0.70-1.83) 4 to 9 0.93 (0.62-1.38) 0.87 (0.58-1.30) 10 to 12 1.33 (0.90-1.95) 1.30 (0.87-1.94) More than 12 1.65 (1.05-2.58)* 1.50 (0.95-2.37) aAdjusted for: certification level, EMS experience, work status, provider monthly call volume, main EMS agency type, main EMS agency community size b Referent groups: those who indicated that they did have this element of the work environment. *p<0.05

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5.4.4 Work-Related Burnout and Job Resources

After controlling for important confounding variables (Figure 9), select job resources were associated with decreased odds of work-related burnout. Receiving performance feedback from either a medical director (OR: 0.46, 95% CI: 0.34-0.61) or supervisor (OR: 0.36, 95% CI: 0.28-0.47) was associated with reduced odds of work- related burnout. Only two benefits, paid uniforms (OR: 0.54, 95% CI: 0.39-0.76) and tuition assistance (OR: 0.62, 95% CI: 0.48-0.79) were associated with work-related burnout. Meanwhile, those who did not depend on overtime pay to make ends meet demonstrated 63% reduced odds of work-related burnout compared to those who reported depending on overtime pay (OR: 0.37, 95% CI: 0.28-0.48). Providers who worked for an agency where they perceived that personnel input was received were at 75% reduced odds of work-related burnout compared to providers at agencies where they reported personnel input was not well received (OR: 0.25, 95% CI: 0.20-0.33). Respect from supervisors (OR: 0.19, 95% CI: 0.13-0.28) and co-workers (OR: 0.22, 95% CI: 0.13-

0.36) were also strongly associated with reduced odds of work-related burnout. Providers who reported adequate orientation (OR: 0.36, 95% CI: 0.28-0.45) and training (OR: 0.35,

95% CI: 0.27-0.45) also demonstrated reduced odds of work-related burnout. Table 19 displays the unadjusted and adjusted odds ratios for job resources and work-related burnout.

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Table 19. Unadjusted and Adjusted Odds Ratios for the Association between Job Resources and Work-Related Burnout Variable Unadjusted OR Adjusted OR (95% CI) (95% CI)a Performance Feedback Medical Director No Referent Referent Yes 0.45 (0.34-0.60)* 0.46 (0.34-0.61)* Supervisor No Referent Referent Yes 0.36 (0.29-0.46)* 0.36 (0.28-0.47)* Rewards Benefitsb Paid vacation 1.55 (1.11-2.18)* 1.11 (0.67-1.84) Paid sick leave 1.28 (0.98-1.69) 0.93 (0.65-1.33) Health insurance 1.39 (1.05-1.83)* 0.93 (0.59-1.45) Dental insurance 1.26 (0.97-1.64) 0.80 (0.52-1.24) Vision insurance 1.13 (0.88-1.45) 0.76 (0.52-1.11) Uniform allowance 0.82 (0.64-1.04) 0.79 (0.61-1.02) Paid uniforms 0.66 (0.49-0.89)* 0.54 (0.39-0.76)* Tuition assistance 0.67 (0.53-0.86)* 0.62 (0.48-0.79)* Retirement plan 1.31 (0.97-1.78) 0.99 (0.64-1.54) Depend on overtime pay Yes Referent Referent No 0.33 (0.25-0.44)* 0.37 (0.28-0.48)* Job Control Job autonomy No Referent Referent Yes 0.35 (0.27-0.45)* 0.34 (0.26-0.44)* Control over schedule No Referent Referent Yes 0.30 (0.23-0.39)* 0.30 (0.23-0.40)* Participation Personnel input is well-received No Referent Referent Yes 0.25 (0.19-0.31)* 0.25 (0.20-0.33)* Supportive Environment Management support No Referent Referent Yes 0.19 (0.15-0.25)* 0.20 (0.15-0.27)* Respect from supervisor No Referent Referent Yes 0.19 (0.14-0.27)* 0.19 (0.13-0.28)* Respect from co-workers No Referent Referent Yes 0.22 (0.14-0.37)* 0.22 (0.13-0.36)* Continued

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Table 19. Continued Variable Unadjusted OR Adjusted OR (95% CI) (95% CI)a Knowledge Orientation No Referent Referent Yes 0.35 (0.28-0.43)* 0.36 (0.28-0.45)* Training No Referent Referent Yes 0.34 (0.27-0.42)* 0.35 (0.27-0.45)* aAdjusted for: certification level, EMS experience, work status, main EMS agency type, main EMS agency community size bReferent groups: those who indicated that they did not have this benefit. *p<0.05

5.4.5 Patient-Related Burnout and Confounding Variables

Provider certification level was the only confounding variable that demonstrated a significant association with patient-related burnout. EMS professionals certified at the

AEMT or paramedic level had an 84% increase in odds of patient-related burnout compared to EMTs (OR: 1.84, 95% CI: 1.23-2.75). Nevertheless, EMS experience, full- time work status, main EMS agency type, and main EMS agency community size were included in the multivariable models since these variables were hypothesized a priori to confound the relationship between job characteristics and patient-related burnout (See

Table 20).

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Table 20. Odds Ratios for the Association between Confounding Variables and Patient- Related Burnout Variable Univariable OR (95% CI) Certification Level EMT Referent AEMT/Paramedic 1.84 (1.23-2.75)* EMS Experience Less than 5 years Referent 5 to 15 years 1.30 (0.81-2.08) More than 15 years 1.25 (0.76-2.08) Work status Part-time Referent Full-time 1.80 (0.95-3.38) Main Agency Type Fire-based Referent Governmental, non-fire based 1.22 (0.74-2.01) Hospital-based 0.89 (0.47-1.69) Private, non-hospital based 0.54 (0.29-1.01) Community, non-profit 0.77 (0.32-1.89) Main EMS Agency Community Size Rural Referent Urban 1.24 (0.76-2.03)

5.4.6 Patient-Related Burnout and Job Demands

After controlling for certification level, EMS experience, full-time work status, main EMS agency type, and main EMS agency community size, certain job demands demonstrated a significant relationship with the odds of experiencing patient-related burnout. Providers reporting that they had to hurry between calls had a more than four- fold increase in odds of patient-related burnout (OR: 4.22, 95% CI: 2.47-7.23).

Frequently posting in an emergency vehicle was associated with a two-fold increase in odds of patient-related burnout (OR: 2.00, 95% CI: 1.30-3.10). With regards to work environments, those that did not include a place to eat/prepare food (OR: 3.75, 95% CI:

2.25-6.23), shower (OR: 2.99, 95% CI: 1.97-4.54), or relax (OR: 2.86, 95% CI: 1.63-

5.03) demonstrated the strongest association with patient-related burnout. Shift work did

119 not demonstrate a significant association with patient-related burnout. Table 21 displays the unadjusted and adjusted odds ratios for job demands and patient-related burnout.

Table 21. Unadjusted and Adjusted Odds Ratios for the Association between Job Demands and Patient-Related Burnout Variable Unadjusted OR Adjusted OR (95% CI) (95% CI)a Workload Provider Call Volume Past 30 Days 1.00 (1.00-1.01)* 1.00 (1.00-1.01)* Time Pressure No Referent Referent Yes 4.56 (2.67-7.79)* 4.22 (2.47-7.23)* Patient Contact Main EMS Agency Service Type Emergent Referent Referent Non-Emergent 1.53 (0.90-2.59) 0.78 (0.42-1.47) Physical Environment Post in emergency vehicle Never/Seldom/Sometimes Referent Referent Often/Always 1.78 (1.24-2.57) 2.00 (1.30-3.10)* Work environment does NOT include a place to:b Sleep 1.31 (0.88-1.94) 1.63 (1.01-2.64)* Shower 1.85 (1.24-2.76)* 2.99 (1.97-4.54)* Eat/prepare food 3.01 (1.91-4.76)* 3.75 (2.25-6.23)* Store belongings 1.94 (1.30-2.88)* 2.45 (1.58-3.81)* Exercise 2.18 (1.36-3.49)* 2.78 (1.64-4.72)* Relax 2.33 (1.37-3.99)* 2.86 (1.63-5.03)* Shift work Number of shifts ≥24 hours None Referent Referent 1 to 3 1.30 (0.69-2.46) 0.99 (0.46-2.12) 4 to 9 0.74 (0.35-1.55) 0.65 (0.31-1.33) 10 to 12 1.31 (0.78-2.21) 1.07 (0.60-1.90) More than 12 1.64 (0.89-3.03) 1.41 (0.77-2.57) Number of overnight shifts None Referent Referent 1 to 3 0.74 (0.36-1.51) 0.62 (0.30-1.29) 4 to 9 1.00 (0.57-1.73) 0.81 (0.47-1.41) 10 to 12 1.08 (0.60-1.94) 0.85 (0.46-1.55) More than 12 1.53 (0.92-2.53) 1.23 (0.74-2.04) aAdjusted for: certification level, EMS experience, work status, main EMS agency type, main EMS agency community size bReferent groups: those who indicated that they did have this element of the work environment. *p<0.05

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5.4.7 Patient-Related Burnout and Job Resources

After controlling for confounding variables, several job resources demonstrated a significant association with odds of patient-related burnout (Table 22). Feedback from medical directors (OR: 0.51, 95% CI: 0.33-0.79) and supervisors (OR: 0.47, 95% CI:

0.33-0.68) was associated with reduced odds of patient-related burnout. As for benefits, only paid vacation (OR: 0.47, 95% CI: 0.22-0.99), paid uniforms (OR: 0.54, 95% CI:

0.34-0.86), and tuition assistance (OR: 0.54, 95% CI: 0.35-0.84) were significantly associated with odds of patient-related burnout. Those who reported that they did not depend on overtime pay to make ends meet had 54% lower odds of patient-related burnout compared to those who said they depended on overtime pay. Respect from supervisor (OR: 0.42, 95% CI: 0.25-0.69) was associated with decreased odds of patient- related burnout while respect from co-workers was not statistically significant. Adequate orientation (OR: 0.53, 95% CI: 0.36-0.77) and training (OR: 0.42, 95% CI: 0.29-0.62) were significantly associated with reduced odds of patient-related burnout. Table 22 contains the unadjusted and adjusted odds ratios for job resources and patient-related burnout.

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Table 22. Unadjusted and Adjusted Odds Ratios for the Association between Job Resources and Patient-Related Burnout Variable Unadjusted OR Adjusted OR (95% CI) (95% CI)a Performance Feedback Medical Director No Referent Referent Yes 0.47 (0.30-0.73)* 0.51 (0.33-0.79)* Supervisor No Referent Referent Yes 0.46 (0.32-0.66)* 0.47 (0.33-0.68)* Rewards Benefitsb Paid vacation 1.17 (0.70-1.96) 0.47 (0.22-0.99)* Paid sick leave 1.12 (0.71-1.75) 0.62 (0.35-1.10) Health insurance 1.22 (0.75-1.98) 0.58 (0.27-1.22) Dental insurance 1.20 (0.75-1.93) 0.58 (0.30-1.16) Vision insurance 1.06 (0.70-1.60) 0.59 (0.35-1.00) Uniform allowance 0.95 (0.65-1.37) 0.87 (0.61-1.23) Paid uniforms 0.86 (0.55-1.34) 0.54 (0.34-0.86)* Tuition assistance 0.56 (0.37-0.86) 0.54 (0.35-0.84)* Retirement plan 1.60 (0.99-2.59) 0.82 (0.43-1.56) Depend on overtime pay Yes Referent Referent No 0.16 (0.12-0.20)* 0.46 (0.28-0.77)* Job Control Job autonomy No Referent Referent Yes 0.53 (0.36-0.78)* 0.50 (0.34-0.73)* Control over schedule No Referent Referent Yes 0.39 (0.27-0.54)* 0.43 (0.31-0.61)* Participation Personnel input is well-received No Referent Referent Yes 0.39 (0.27-0.55)* 0.39 (0.27-0.56)* Supportive Environment Management support No Referent Referent Yes 0.30 (0.21-0.43)* 0.32 (0.22-0.46)* Respect from supervisor No Referent Referent Yes 0.41 (0.25-0.67)* 0.42 (0.25-0.69)* Respect from co-workers No Referent Referent Yes 0.57 (0.29-1.14) 0.55 (0.28-1.06) Continued

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Table 22. Continued Variable Unadjusted OR Adjusted OR (95% CI) (95% CI)a Knowledge Orientation No Referent Referent Yes 0.49 (0.34-0.71)* 0.53 (0.36-0.77)* Training No Referent Referent Yes 0.39 (0.27-0.57)* 0.42 (0.29-0.62)* aAdjusted for: certification level, EMS experience, work status, provider monthly call volume, main EMS agency type, main EMS agency community size bCompared to those who indicated that they did not have this benefit. *p<0.05

5.4.8 The Association of High/Low Job Demands and High/Low Job Resources with

Burnout

The median points assigned for job demands was 12 (IQR: 9-14) out of a possible

26 points. For job resources, the median composite score was 26 (IQR: 20-31) out of a possible 42 points. Table 23 displays the cross-tabulation for EMS professionals experiencing high and low job demands and resources. A total of 31.8% of EMS professionals experienced the desirable condition of low job demands with high job resources. Meanwhile, 29.9% experienced the undesirable condition of high job demands with low job resources.

After adjusting for important confounding variables, compared to those with low job demands and high job resources, those with high job demands and low job resources had 9.84 times the odds of work-related burnout (95% CI: 6.72-14.41). The odds of patient-related burnout for EMS professionals with high job demands and low job resources were 6.47 times (95% CI: 3.61-11.59) those of EMS professionals with low job demands and high job resources (See Table 24 ).

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Table 23. Proportion of EMS Professionals with High and Low Job Demands and Job Resources Job Demands Job Resources High Low High 21.3% (271) 31.8% (404) Low 29.9% (380) 17.0% (216)

Table 24. Odds of Work-Related and Patient-Related Burnout by Job Demands and Job Resources Status Unadjusted OR Adjusted OR (95% CI) (95% CI)a Work-Related Burnout Low Demands High Resources Referent Referent Low Demands Low Resources 4.46 (3.18-6.26)* 5.00 (3.41-7.33)* High Demands High Resources 2.03 (1.41-2.91)* 1.91 (1.32-2.76)* High Demands Low Resources 9.84 (6.72-14.41)* 9.50 (6.39-14.10)* Unadjusted OR Adjusted OR (95% CI) (95% CI)a Patient-Related Burnout Low Demands High Resources Referent Referent Low Demands Low Resources 3.79 (2.07-6.94)* 3.73 (2.03-6.86)* High Demands High Resources 2.87 (1.60-5.14)* 2.67 (1.54-4.64)* High Demands Low Resources 6.84 (3.80-12.29)* 6.47 (3.61-11.59)* aAdjusted for: certification level, EMS experience, work status, provider monthly call volume, main EMS agency type, main EMS agency community size *p<0.05

5.4.9 Non-Responder Results

There were 223 responses to the non-responder questionnaire, which resulted in the ability to detect a practically relevant 10% difference in work-related burnout with greater than 80% power. The presence of work-related burnout did not differ significantly between responders to the full questionnaire and those who participated in the abbreviated non-responder survey (p=0.113). Differential response rates were detected for certification level, as a larger proportion of EMTs responded to the full questionnaire compared to the non-responder survey (36.6% vs. 45.5%). This finding is consistent with

124 previous work among EMS professionals showing that paramedics responded at a higher rate compared to EMTs (14% vs. 11%).24 There were no differences detected between responders and non-responders with regards to other key characteristics including sex, currently practicing in EMS, full-time work status, or years of EMS experience (Table

25).

Table 25. Comparison of All Full Questionnaire and Non-Responder Questionnaire Participant Characteristics Full Non-Responder p-value Questionnaire Questionnaire Participants Participants (N=1,490) (N=223) Sex 0.596 Female 26.6 (391) 28.3 (63) Male 73.4 (1,081) 71.8 (160) Currently Working in EMS 0.769 Yes 94.2 (1,401) 93.7 (209) No 5.8 (86) 6.3 (14) Employment Status at Main EMS 0.736 Agency Full-time 15.6 (215) 14.6 (30) Part-time 84.5 (1,168) 85.4 (175) Years of EMS Experience 0.953 Less than 5 years 17.8 (250) 18.6 (39) 5 to 15 years 42.4 (596) 42.4 (89) More than 15 years 39.9 (561) 39.1 (82) Certification Level 0.002 EMT 36.6 (502) 45.5 (91) AEMT/EMT-I 5.8 (80) 9.5 (19) Paramedic 57.5 (788) 45.0 (90) Work-related Burnout 0.113 Yes 63.1 (864) 57.4 (117) No 36.9 (505) 42.7 (87)

5.5 Discussion

This study identified specific job demands and resources that are strongly associated with occupational burnout among EMS professionals. After accounting for clustering at the agency level and controlling for confounding variables, time pressure

125 and elements of the physical environment were related to increased odds of experiencing both work-related and patient-related burnout. Meanwhile, feedback, rewards, job control, participation, supportive environment, and knowledge were related to decreased odds of experiencing both work-related and patient-related burnout. These findings add to the literature on burnout in EMS by quantifying the relationship between burnout and specific job demands and resources. Prior research on burnout among EMS professionals has primarily examined non-modifiable individual (e.g., sex, provider level, years of experience) and agency characteristics (e.g., agency type).24

Another important finding from this study was that many EMS professionals experiencing burnout demonstrated work-related burnout alone; however, few experienced patient-related burnout alone. The finding that a large group of EMS professionals scored high on the work-related burnout scale and low on the patient- related burnout scale supports the differentiation between these two domains of burnout.128 While previous work has shown that patient-related burnout is less common than work-related burnout among EMS professionals, to our knowledge, no studies have examined the proportion of those experiencing patient-related burnout who simultaneously experienced work-related burnout.24 In this study, of those experiencing patient-related burnout, most were also experiencing work-related burnout. This finding potentially suggests that patient-related burnout develops after work-related burnout, though it is not possible to confirm this hypothesis through these cross-sectional data.

Some studies of the Maslach Burnout Inventory have found that emotional exhaustion leads to cynicism with clients or patients.140 Nevertheless, cynicism may represent a coping strategy and does not completely reflect the physical and emotional exhaustion

126 attributed to work with patients that the Copenhagen Burnout Inventory patient-related burnout subscale meaures.13

Of the job demands related to burnout in EMS, time pressure demonstrated the strongest association with both work-related and patient-related burnout. This finding is consistent with previous research from other settings as a meta-analysis by Lee and

Ashforth that found that time-pressure accounted for 25% of the variance in emotional exhaustion, which is a dimension on the Maslach Burnout Inventory.139 This finding is concerning as more than 70% of providers in this study reported having to hurry between calls because they have too much work to do. Encouraging agency leadership to take measures to reduce time pressure in a profession like EMS that is characterized by time pressure may be challenging. In a qualitative study of 60 EMS professionals and supervisors involving eight focus groups and 29 individual interviews, barriers to taking a brief time out period (often just 0.5 to 1 hour) after exposure to a critical incident included a culture that stigmatizes vulnerable emotions.149 Providers expressed reluctance to request support and time out of service after a critical incident for fear of appearing weak, while supervisors were reluctant to remove a crew from service as maintaining confidentiality of the providers would be nearly impossible.149 Nevertheless, a time out period was seen as one of the most important resources to combat stress after a critical incident, which is important since exposure to critical incidents has been linked with burnout.7,57

With regards to job resources related to burnout in EMS, managerial support demonstrated a strong association with burnout, which is in-line with findings from investigations in other healthcare settings. Nurses who worked for hospitals with reported

127 lower organizational support demonstrated a two-fold increase in odds of experiencing burnout (OR: 2.05, 95% CI: 1.78-2.38) in a study of over 10,000 nurses from the U.S.,

Canada, England and Scotland.90 Among ambulance workers in the Netherlands, social support from the supervisor was significantly correlated with emotional exhaustion

(r=0.40).150 Supervisor support was described by EMS professionals as one of the most valuable resources in facilitating coping with critical incidents.149 Since exposure to critical incidents has been linked to burnout, supervisor support may help alleviate the stress and reduce the impact of these events on providers.

Performance feedback is another potentially modifiable job resource that demonstrated a strong association with burnout. The prevalence of feedback from a medical director or supervisor observed in this study is consistent with findings from a study of nationally-certified EMS professionals where 55% had received any feedback related to the medical care provided in the 30 days preceding the study.107 The strong association between increased performance feedback and reduced odds of burnout identified in this study is consistent with work among other healthcare professionals, as a study of over 700 Dutch home healthcare professionals showed that performance feedback was negatively correlated with emotional exhaustion (r= -0.21).151 The converse is also true in other settings as internal medical residents at five institutions reporting little or no feedback were more likely to develop burnout higher burnout scores.152 In addition to its link to burnout, feedback may serve to improve performance in the prehospital setting and could ultimately improve patient outcomes. In a retrospective chart review of records for patients transported to two hospitals in Rhode Island, hospital-

128 directed feedback related to stroke significantly improved EMS performance on nine out of the 10 measures assessed.153

5.5.1 Job Demands-Resources Model

Overall, the findings of this study support the job demands-resources model.

While some job demands did not demonstrate a statistically significant association with burnout, the job demands that were related to burnout demonstrated a direct relationship, meaning that increased job demands were associated with increased burnout. Similarly, not all job resources were significantly associated with burnout, but those that were demonstrated an inverse relationship, suggesting that increased job resources were associated with decreased odds of burnout.

The finding that certain job demands or resources were not associated with burnout does not represent a contradiction to the model. For example, the finding that shift work was not significantly associated with work-related burnout does not suggest that the job demands-resource model is incorrect. Rather, this finding highlights the benefits of using the job demands-resource model as this theory is flexible across occupations and does not propose specific job demands that are related to burnout. That is one of the key advantages of the job demands-resources model, that it allows for the characteristics that are most important in the relationship with burnout to vary between occupational settings.83

The job demands-resources model proposes two fundamental processes: a health impairment process and a motivational process.89 The health impairment process occurs due to an increase in chronic job demands and a depletion of an employee’s mental and physical energy leading to exhaustion and burnout.119 The motivational process assumes

129 that job resources have the potential to lead to high work engagement even in the face of high job demands.119 Previous work has found that job demands tend to be more strongly related to exhaustion, while job resources are more strongly related with cynicism and disengagement.83,154 While assessing the motivational process of job engagement was beyond the scope of the present study, strong direct relationships were identified between job resources and odds of work and patient-related burnout.

5.5.2 Limitations

One of the most important limitations to this study is the potential for response bias. It is possible those who were more interested in the topic of burnout would be more likely to respond, and that those more interested in the topic would be more likely to be experiencing burnout. The effect of this bias would be prevalence estimates that are higher than the true prevalence of burnout in the target population of South Carolina

EMS professionals. There is some evidence that the burnout estimates identified in this study are higher than estimates found in a national sample of EMS professionals. The prevalence of any work-related burnout in this study was slightly higher than the prevalence observed among a sample of more than 2,000 nationally-certified EMS professionals (Paramedic/AEMT: 41.0% vs. 30.1%; EMT: 31.6% vs. 19.1%).24

Meanwhile, the prevalence of patient related burnout seen in this study among paramedics and AEMTs (13.6%) was similar to the prevalence observed in the national sample (14.4%). Among EMTs, the prevalence of patient-related burnout observed in this study (8.1%) was higher than the prevalence observed in the national study (5.5%).

Nevertheless, the primary interest of this study was not to quantify the prevalence of burnout among EMS professionals in South Carolina, rather we were interested in the

130 relationships between job characteristics and burnout. Multivariable analyses were used to control for confounding factors, including certification level, which is important since the non-responder analysis showed that paramedics were more likely to respond to the full questionnaire compared to EMTs. While the prevalence of burnout may be different between responders and non-responders, the structure and magnitude of the relationships between burnout and job demands and resources are not likely different between responders and non-responders.

Another important limitation of this research stems from the use of cross-sectional data, which prevents causal inference. It is not possible to determine whether burnout was present before exposure to the job demands or resources. Nevertheless, reverse causality does not seem plausible as high levels of burnout would not likely result in a reduction of job resources, like receiving feedback, or an increase in job demands, such as having to hurry between calls. Nevertheless, there is the possibility that other job characteristics that were not measured in this study could have a causal relationship in the development of burnout. One variable that was not measured is exposure to traumatic events. A meta- analysis of burnout in emergency nurses identified exposure to traumatic events as an important determinant of burnout.57 A study of 110 Scottish ambulance personnel further identified a link between exposure to a disturbing incident in the six months preceding the study.7 Nevertheless, providing a common definition of a critical or disturbing incident is difficult and asking EMS professionals to recall the number of critical incidents experienced in a recent time frame could induce hyperarousal symptoms such as sleep disruption, irritability, and other PTSD-related symptoms.149,155 Thus, assessing exposure to critical incidents was not included within the scope of this project.

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The strategy undertaken related to the creation of composite scores for job resources and demands also introduces some limitations to the interpretation of the findings from this study. First, no psychometric scale development analyses were conducted. Instead, a point value was assigned to each response option. For items with four response options, a total of three points were available when binary items were eligible for a maximum of one point. For this analysis, these point values were not intended to be used as weights related to the importance of a job resource or demand, but rather the varying point values were intended to help distinguish between the highest and lowest response levels for each item. More sophisticated scale development methods including Rasch modeling could be used to weight the importance of each item.156

Nevertheless, the objective of this analysis was not to develop a repeatable scale to score job demands and resources, but the goal was to create a basic measure that would allow for assessment of how demands and resources are associated with burnout simultaneously. Next, the decision to create high and low categories for resources and demands using the median composite scores in this sample could preclude comparisons with future studies since the median composite score is likely to differ between samples.

However, again, the objective of this analysis was simply to create a proxy for high and low demands and resources to compare within this study population.

Finally, the decision to analyze burnout as a dichotomous measure introduces limitations to the findings of this study. Burnout was dichotomized using an average score of 50 or higher in the domain, which corresponds to answering “sometimes” or more frequently to statements reflecting the particular type of burnout (work-related or patient-related). The use of a cut point to divide scores into groups supposes that there is

132 an underlying dichotomy and in this case, that those on the lower side of cut point do not demonstrate symptoms of burnout whereas those on the higher side of the cut point do.

Individuals who are close to but on opposite sides of the cut point are treated as if they are very different in terms of demonstrating burnout, when they may in fact be similar.157

Nevertheless, there is no objective diagnostic test to determine the presence of burnout.

Categorization of burnout into meaningful groups of those who likely demonstrate the mental and physical exhaustion central to the construct simplifies the interpretation of results. Further, treating the composite burnout score from variables that were measured using an ordinal scale as continuous data is not appropriate as this assumes that each point on the composite score is equal distance from the next point. That is to say, that the distance between often and almost always/always is the same as the distance between seldom and sometimes.156 Thus, creating meaningful categories is more appropriate for this type of data. The scoring and cut point of 50 recommended by the authors of the tool was used to facilitate comparison between studies, rather than taking another common approach of using the median as a cut point, which would introduce various cut points across studies limiting future comparisons and meta-analysis.157 Using a cut point was adopted based on recommendations from authors of the tool and does not reflect a clinical cut point.

5.5.3 Implications and Future Directions

While this cross-sectional study is unable to determine causality between job characteristics and burnout, actionable links between certain job demands, resources and burnout were identified. When job demands are high and cannot be easily modified, such as call volume, EMS agency leadership may implement measures to increase the

133 available job resources to mitigate the effects of job demands. Previous work has shown that increasing job resources, particularly when job demands are high has a protective effect against burnout.85

Some of the job resources linked to burnout identified in this study can be increased among EMS agencies with little financial cost. For example, leadership support and respect for EMS personnel is an undervalued and potentially modifiable job resource that demonstrated a strong relationship with burnout. The findings from this study demonstrating a significant link between managerial support and respect with both work and patient-related burnout underscore the importance of a supportive workplace culture.

Previous research has found that a rewarding transformational leadership style was correlated with reduced emotional exhaustion, while passive laissez-faire leadership was related to increased emotional exhaustion.158 EMS agencies should monitor leadership style and employee perceptions of leadership as an aspect of organizational culture and identify ways to improve support for personnel.

Provision of feedback is another important modifiable job resource that has the potential to reduce burnout in EMS and improve patient outcomes. Examples of interventions that could be implemented at the EMS agency level to improve clinical performance feedback include feedback reports related to compliance with protocols, benchmarking and medical director walk rounds. The use of achievable benchmarks has been shown to increase the effectiveness of physician performance.159 Feedback reports from supervisors, medical directors or medical facilities may be effective in promoting adherence to protocols and improve quality of care.153 In addition to reduced burnout, exposure to leadership walk rounds in neonatal intensive care units was associated with

134 better patient safety culture.160 Implementing medical director visits that include specific agency performance feedback may be a cost-effective tool to help reduce provider burnout, promote better quality of care, and improve patient safety. Future work is needed to evaluate whether positive or negative feedback affects burnout differently.

Because the current study was unable to demonstrate a causal association between job characteristics and burnout, future prospective longitudinal work is needed to determine whether job characteristics have a direct impact on burnout and more importantly, whether modifying specific job characteristics is effective to reduce burnout.

One of the job demands that warrants future investigation due to its strong association with both work and patient-related burnout is time pressure. In particular, further research is needed to understand the causes of time pressure in EMS and whether or not these causes are modifiable. For example, providers may experience job strain when they are unable to complete documentation after a call before being dispatched to the next response. In a 1988 study of paramedics in South Carolina, perception of paperwork load were significantly correlated with burnout116; however, research evaluating the relationship between documentation requirements and burnout since many services have transitioned to electronic medical records has not been evaluated in the prehospital setting. Identifying causes of time pressure in EMS may require future qualitative and quantitative work. For example, some of the barriers may be culture-related in a profession like EMS known for time pressure and hurrying, taking time out of service after a call to complete work may be seen negatively.149 Meanwhile, quantitative analysis of the number of providers available and call volume may elucidate whether problems may be related to inadequate staffing.

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5.6 Conclusions

Our study provides insight into some of the job demands and resources that are strongly associated with burnout among EMS professionals. Congruent with the job demands resources model, these findings suggest that in general, increased job demands are associated with higher odds of burnout whereas increased job resources are associated with reduced odds of burnout. While we are not able to say that specific job demands and resources cause burnout, our study serves as guidance for future prospective work to test whether reducing job demands like time pressure or increasing job resources such as feedback and leadership support for EMS personnel reduces occupational burnout among this important healthcare provider population.

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Chapter 6. The Association of Burnout with Turnover, Sickness Absence, and

Occupational Injury among EMS Professionals (Aim 3)

6.1 Abstract

Introduction: Emergency medical services (EMS) professionals face a variety of mental and physical stressors that could place their well-being and long-term careers at risk.

Occupational burnout may lead EMS professionals to seek ways to conserve resources either by leaving the job or taking sick days. EMS professionals experiencing burnout who do not retreat from work may instead, conserve resources by taking shortcuts which could lead to occupational injury. The objective of this study was to assess the relationship between burnout and turnover, sickness absence, and occupational injury among EMS professionals.

Methods: This was a prospective cohort study of EMS professionals working for a large county-based EMS agency in North Carolina. Burnout was assessed at baseline using an electronic questionnaire administered in November of 2017. The Copenhagen Burnout

Inventory was used to measure two domains of burnout: work-related burnout and patient-related burnout. Turnover, sickness absences and occupational injuries occurring after administration of the baseline questionnaire were obtained from company records.

Analysis for this paper included data collected from December 1, 2017 to May 13, 2018, though observation for this study will continue through November 30, 2018. Generalized linear models were used to estimate risk ratios comparing providers experiencing burnout to those who were not experiencing burnout for the three outcomes of interest and

137 multivariable models were used to adjust for important confounding variables selected a priori.

Results: A total of 238/425 (56.0%) of EMS professionals responded to the baseline questionnaire. Responders were more likely to be female, older, certified at the paramedic level, incur five or more sick days, and to have remained at the agency compared to non-responders. Nearly 5% of respondents left the agency, 34% took five or more sick days, and 8% incurred an occupational injury. Due to the low number of outcome events observed, multivariable analyses were not conducted. Nearly half of respondents were experiencing at least one type of burnout (48.1%), and of those experiencing burnout, 43.8% were experiencing both work-related and patient-related burnout. The crude risk of leaving the agency was over three-fold higher among those experiencing work-related burnout compared to those not experiencing burnout at baseline (RR: 3.30, 95% CI: 0.97-11.26); however, this difference was not statistically significant. EMS professionals experiencing work-related burnout demonstrated 60% greater risk of missing four or more days of work compared to those not experiencing burnout (RR: 1.60, 95% CI: 1.15-2.22). There was no difference in risk of occupational injury by burnout status in this study.

Conclusion: These results suggest a relationship between burnout and withdrawal from work either through increased sickness absence or turnover. Meanwhile, burnout was not associated with higher risk of occupational injury in this study. However, the ability to detect differences in this study may have been limited by the small number of injuries observed during the study period. Future work is needed to examine the potential association between burnout and injuries generated as a result of workarounds.

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6.2 Introduction

Emergency medical services (EMS) professionals serve as an important initial link in the healthcare continuum, providing acute care to ill and injured patients in the out-of-hospital setting. With the demand for emergency medical responses exceeding 28 million calls annually and expected to grow as the average age of the U.S. population increases, recruitment and retention of a healthy workforce of EMS professionals is important to meet this critical public health need.1 Workforce shortages are a major concern for key stakeholders including EMS agency management and local government, in both urban and rural settings.161,162 Over half (57%) of rural EMS agency directors reported that their agency was not fully staffed, while 50% of directors at urban agencies reported unfilled vacancies.163 Meanwhile, annual turnover at EMS agencies has been estimated at nearly 11% with a median cost of more than $70,000 per agency.117

EMS professionals face a variety of physical and psychological stressors that could place their well-being and long-term careers at risk. Working in the prehospital setting often involves high physical demands, such as lifting patients, carrying heavy equipment up flights of stairs, or descending steep embankments.3 Mental demands commonly encountered in providing prehospital care include complex decision-making under time pressure with limited information, while high emotional demands include exposure to traumatic events, such as the death of a child and car collisions involving multiple fatalities.38,80 These intense stressors may place EMS professionals at risk for occupational burnout, which may, in turn, negatively affect workforce stability.

Burnout is a condition characterized by extreme emotional and physical exhaustion that is perceived by the person as being related to his or her work.13 Burnout

139 has been associated with forms of job withdrawal including absenteeism and turnover.18,65,135 In a study of more than 2,000 nationally-certified EMS professionals, burnout was linked to over a two-fold increase in odds of reporting ten or more sickness absences in the past 12 months and over a three-fold increase in odds of intending to leave the EMS profession within the next year.24 Another study of EMS professionals at a single agency in the Midwest showed a significant correlation between burnout and turnover intentions.79 Nevertheless, these studies were cross-sectional and unable to demonstrate a causal relationship between burnout and turnover among EMS professionals.

In addition to leading professionals to disengage from work either by resigning or taking sick days, burnout may place EMS professionals at greater risk for safety hazards and occupational injury. Compared to other occupations, EMS professionals are at higher risk for on-the-job injury. The average number of occupational illnesses and injuries requiring medical attention at the emergency department was nearly 22,000 in 2001 and

2002.164 Between 2003 and 2007, the rate of fatal occupational injuries was nearly 1.5 times greater among EMS professionals compared to other workers at 6.3 deaths per

100,000 providers.29 The mental and physical exhaustion central to burnout and ensuing lack of commitment to the job may place workers experiencing this condition at higher risk for injury. While, to our knowledge, no studies have linked burnout to occupational injury in EMS, burnout has been linked to increased risk of injury in other healthcare settings, including nursing.27,74,75

The objective of this study was to quantify the relationship of burnout with turnover, sickness absence, and occupational injury among EMS professionals. We

140 hypothesized that EMS professionals experiencing the mental and physical exhaustion characteristic of burnout would be more likely to take absences from work, leave a job, or suffer occupational injury than those who were not experiencing burnout. If burnout is associated with turnover, this significantly undermines agency investments in training and retaining employees. Further, increased unscheduled sickness absence leaves employers scrambling to fill empty shifts and may negatively impact other employees who are required to work overtime in order to meet emergency services coverage needs.

Finally, an increase in occupational injury among employees experiencing burnout implies a direct negative effect on the well-being of the provider and may result in high costs to the EMS organization.

6.2.1 Theoretical Framework: Conservation of Resources Model

This work was guided by the conservation of resources model of stress and burnout. The conservation of resources theory was originally proposed in 1989 by

Hobfoll to explain the nature of stress.84 The basis of this theory is that people strive to maintain and create resources that they value and when these resources are threatened, stress occurs.84 According to this theory, stress is defined as a person’s reaction under three threats: 1) when resources are threatened with loss; 2) when resources are actually lost; 3) when the person fails to gain resources following investment of personal resources.84 The conservation of resources theory defines four types of resources: 1) objects- things that have a physical presence; 2) conditions- structures or states, such as social relationships; 3) personal characteristics-individual traits or coping skills; 4) energy- skills and abilities that can be exchanged for other resources.84

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Although originally designed to explain the development of stress, the conservation of resources theory has also been applied to burnout as a special form of occupational stress with emotional exhaustion as the core characteristic.20,93 Based on the conservation of resources model, burnout results when the individual perceives a threat to existing resources or fails to gain resources after investment of existing resources over a long period of time.25 For example, an EMS professional may invest significant time and energy in satisfying patient wants and fail to receive economic rewards or recognition for high patient satisfaction scores. Over time, high demands result in a depletion and wearing down of energetic resources and result in burnout.94 As an employee experiences burnout, he or she is more careful with how future resources are invested in work.25,26

Employees may engage in a variety of behaviors to preserve energetic resources including withdrawal from work or finding ways to invest less energy in work while remaining on the job.25,26

One way employees experiencing burnout may attempt to conserve resources is through withdrawing from work either temporarily (absenteeism) or long-term (turnover).

This idea has been supported by study among prison guards demonstrating that emotional exhaustion led to increased absenteeism.95 Employees experiencing burnout may refrain from investing further resources at work by choosing to stay home or resigning from the job. Therefore, we hypothesized:

Hypothesis 1: EMS professionals experiencing burnout will be more likely to leave the EMS agency than those who are not experiencing burnout.

Hypothesis 2: EMS professionals experiencing burnout will have more workplace absences than those who are not experiencing burnout.

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Another way to conserve resources while remaining at work is to refrain from engaging in behaviors perceived as non-essential. For employees experiencing burnout, safety behaviors may be seen as discretionary behavior that require additional resources, especially in routine settings where engaging in expected safety behaviors is not rewarded.27 For example, in EMS, when moving a patient down a flight of stairs, use of a transfer chair is recommended. However, the use of such a device might be perceived as cumbersome and unnecessary for this routine task. Thus, the EMS professional may choose to carry the patient without the assist device and be at increased risk for musculoskeletal injury. A 2007 study by Halbesleben found that burnout was positively associated with safety workarounds, which in turn were related to occupational injuries.27

From the conservation of resources theory, when faced with the decision to follow safety protocols or engage in a workaround to get the work done, employees experiencing burnout may be more likely to engage in workarounds. These workarounds place workers at increased risk for occupational injury. Thus, we hypothesized:

Hypothesis 3: EMS professionals experiencing burnout will more likely to sustain an occupational injury than those who are not experiencing burnout.

6.2.2 Current Study

The current study assessed burnout among a cohort of EMS professionals at baseline and prospectively observed the incidence of turnover, sickness absence, and occupational injury. The objective of this study was to quantify the relationship of burnout with turnover, sickness absence, and injury. This study will fill several gaps in the EMS burnout literature. First, previous investigations have been cross-sectional in nature. Further, previous work has relied on self-reported data regarding sickness absence

143 and turnover intention. Using data gathered through occupational records, this study will provide insight into whether or not turnover, absenteeism, and occupational injury occur more frequently among employees experiencing burnout. This study will provide stronger evidence for a potential causal relationship between burnout and these factors that negatively impact the EMS workforce.

Quantifying the relationship between burnout and turnover, illness and injury will provide insight into whether or not combatting burnout may be an effective strategy for retaining EMS professionals in the workforce. Policies and interventions to reduce burnout then may have a positive effect on the overall stability of the EMS workforce.

The long-term goal of this research is to improve the health of EMS professionals. By providing key stakeholders with guidance into magnitude of burnout’s impact on EMS professionals, interventions may be designed to reduce burnout and in turn may have a positive impact on the longevity of EMS professionals in the profession.

6.3 Methods

6.3.1 Study Design, Population, and Setting

This was a prospective, observational cohort study of EMS professionals working for Mecklenburg EMS Agency. A baseline electronic questionnaire was administered to assess burnout and providers were followed prospectively for 12 months to assess for turnover, workplace absences, and occupational injuries through company records. A period of 12 months was selected based on historical data from the EMS agency to observe a sufficient number of cases to be able to model the outcomes of interest and control for confounding variables. Using a 12 month period also permits comparisons

144 between this study and results from a previous study of burnout, turnover and sickness absence conducted among nationally-certified EMS professionals.24

Mecklenburg EMS Agency is a county-based agency located in North Carolina and employs approximately 400 EMS professionals. The coverage area for this agency includes over 1,000,000 residents and Mecklenburg EMS Agency responds to around

137,000 calls per year. This project was limited to a single agency in an effort to increase internal validity by investing available resources in improving response rate within a single population. Use of a single agency was also employed to avoid introducing between-agency effects due to differences in practice settings and workplace characteristics. The EMS agency for this study was recruited by convenience.

6.3.2 Data Collection

The baseline survey instrument included the work-related and patient-related subscales of the Copenhagen Burnout Inventory to measure burnout. Potential confounding variables assessed through the questionnaire included number of children in the household, number of EMS organizations worked for, and years of EMS experience.

Appendix F contains the final questionnaire.

To encourage participation among employees at Mecklenburg EMS Agency, two weeks prior to administering the baseline questionnaire, employees were advised of this study as part of their regularly scheduled mandatory continuing education sessions.

Appendix G contains the prenotification slide that was presented to employees at their training sessions. Prenotification and support from authoritative sources have been shown to improve participation in research questionnaires.104

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In November of 2017, an invitation to participate in an electronic questionnaire was sent to all EMS employees at Mecklenburg EMS Agency by e-mail (Appendix H).

The e-mail was sent from Mecklenburg EMS Agency’s internal messaging system from the Public Information Specialist in an effort to avoid e-mails being filtered into spam folders and to encourage EMS professionals to open the message from a known member of the company. The e-mail contained a link to the questionnaire and an explanation of rights as a participant. Participation was entirely voluntary and had no bearing on an individual’s employment at Mecklenburg EMS Agency. Further, participants were informed that no one at Mecklenburg EMS Agency would have access to individual survey responses. No personal identifying information was collected. Each employee was permitted to answer the questionnaire once. Responses were collected using

SurveyGizmo software (Widgix, LLC; Boulder, CO).

To further encourage participation, two reminder e-mails were sent to EMS professionals who had not yet answered the survey. Reminder e-mails were sent seven and 14 days after the initial e-mail invitation. Use of repeated, appropriate contact with the study population has been shown to increase response.106 As an added incentive for participation, EMS professionals who responded to the questionnaire were entered in a drawing for one of five Amazon gift cards worth $100 each.

While this study is scheduled to continue through November 2018, the analysis presented here encompasses outcome data collected from December 1, 2017 through May

13, 2018. Outcomes were collected through occupational records maintained by

Mecklenburg EMS agency using a unique randomly assigned identification number to link occupational data to survey responses. This project was approved by the institutional

146 review board at The American Institutes for Research and a waiver of documented consent was granted. The institutional review board at The Ohio State University ceded oversight of this project to the institutional review board at the American Institutes for

Research.

6.3.3 Measures

6.3.3.1 Dependent Variables

Workplace absences for each employee during the study were obtained from occupational records at Mecklenburg EMS agency. Sickness absence was defined as any sick leave, paid or unpaid.

Turnover was determined by termination dates occurring after the study start date, obtained from company records for employees who left the Mecklenburg EMS Agency during the study period.

Occupational injuries were also obtained from company records. Employees are required to report any injury occurring while at work, whether requiring medical attention or not, to officials at Mecklenburg EMS Agency. Mecklenburg EMS Agency maintains a complete database of reported occupational injuries that includes information regarding the date of the incident, anatomical location of injury (e.g., back, foot, fingers), type of injury (e.g., overexertion, slip and fall), and cause of injury (e.g., lifting, vehicle collision, combative patient). Mecklenburg EMS Agency supplied a spreadsheet with all injuries sustained between December 1, 2017 and May 13, 2018.

6.3.3.2 Independent Variables

The exposure variables of interest for this study were work-related and patient- related burnout as measured by the Copenhagen Burnout Inventory (Table 26). Both

147 scales have previously demonstrated adequate reliability as measured through Cronbach’s alpha exceeding 0.70 among a population of nationally-certified EMS professionals

(work-related burnout subscale: 0.89; patient-related burnout subscale: 0.91).24

The work-related burnout subscale consists of seven items designed to measure the degree of mental and physical exhaustion attributed to one’s work.13 Participants are asked to rate how often each statement applied over the past four weeks using a five- point behavioral frequency scale: 1) always/almost always; 2) often; 3) sometimes; 4) seldom; 5) never/almost never. A four-week period was chosen to account for normal variation in shift schedules and special cause variation, such as vacation days.

The patient-related burnout subscale consists of six items designed to measure the degree of mental and physical exhaustion attributed to one’s work with patients.13

Again, participants were asked to indicate how often each statement applied over the previous four weeks using the same a five-point behavioral frequency scale used for work-related burnout.

For both the work-related and patient-related burnout subscales, composite scores were created as specified in the guidelines provided by the authors of the Copenhagen

Burnout Inventory.114 Points were assigned for each response as follows: always/almost always=100, often=75, sometimes=50, seldom=25, and never/almost never=0. For each participant, points were added up across all items in the burnout subscale and divided by the total number of items answered on the subscale. Participants who answered fewer than three items of a subscale were not assigned a composite score. To facilitate comparisons between studies, a dichotomous variable was created for each type of burnout using a composite score of 50 to indicate burnout in the domain.24,114

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6.3.3.3 Confounding Variables

Variables that could confound the relationship between burnout and the outcomes of interest were selected a priori based on previous research. A confounding variable is one that influences both the exposure and outcome variables and could explain the observed difference in outcomes between exposure groups.145 Figure 10 displays the confounding variables identified for the outcomes of turnover and sickness absence and

Figure 11 displays confounding variables for the outcome of occupational injury.

A total of five confounding variables were identified for the workplace withdrawal outcomes of turnover and sickness absence and the outcome of occupational injury:

1) Age. Increased age has been significantly correlated with increased levels of

burnout among paramedics (r=0.23).116 For every one year increase in age, there

was a 5% increase in odds of having a pre-existing medical condition among

EMS professionals.165 In turn, increased odds of medical conditions could

translate to increased sickness absence or the need to stop working. In a

retrospective review of injury records at two large urban EMS agencies, the rate

of injuries per 100 full time workers was significantly lower among EMS

professionals in the 45-54 year old age group (25.6, 95% CI: 20.0-31.1) compared

to those in the 25-34 year old age group (38.9, 95% CI: 33.4-44.3).166 One

explanation for this difference in injury rates is that increased age is associated

with increased years of EMS experience, which could in turn lead to fewer

occupational injuries. Another explanation is that there is a survivorship bias

whereby EMS professionals who are injured at a younger age exit the profession

149 and those who are in the profession longer demonstrate more resilience and avoid injury.

2) Sex. Among nationally-certified EMS professionals, males were at 75% greater odds of experiencing patient-related burnout.24 On average, female workers have been shown to take increased sickness absences compared to males.167,168 As females may be the primary caretakers for children or elderly relatives, they may be more likely to take sick days to deal with family emergencies or resign from a position to take care of a child or relative. A study of fatal and non-fatal injuries among EMS personnel found that females sustained fewer non-fatal injuries requiring emergency department treatment compared to males.29 A plausible explanation for this difference is that females are more likely to occupy non- firefighter EMS roles and injury rates among firefighters tend to be higher.169,170

3) Certification level. A study of nationally-certified EMS professionals found that paramedics demonstrated 48% increased odds of burnout compared to

EMTs.24 The reduced educational requirements necessary to become an EMT may mean that providers certified at this level are able to switch careers more easily than paramedics who have may have invested substantially greater time and financial resources in their education. Providers certified at the paramedic level perform more critical interventions and treat patients that could be violent and place them at greater risk for illness or occupational injury. A study of nationally- certified EMS professionals found that paramedics demonstrated over a two-fold increase in odds of occupational injury compared to EMTs.31

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4) Call volume. Increased call volume represents a job demand that has been

linked to greater odds of burnout among EMS professionals.24 Compared to those

with a moderate call volume, EMS professionals with a very high call volume

were at over a three-fold increase in odds of job-related illness or injury.31

5) Years of EMS experience. EMS professionals with between five and 15 years

of EMS experience were at greater odds of experiencing burnout compared to

EMS professionals with less than five years of experience.24 Compared to those

who worked in EMS for less than one year, those who worked in EMS for more

than five years had over a three-fold increase in odds of occupational injury.31

An additional confounding variable was included in the assessment of the relationships between burnout and turnover and sickness absence.

6) Number of children in the household. The number of children in a household

has also been positively correlated with burnout in paramedics (r=0.19).116 The

presence of children in the household has been linked to increased number and

duration of sickness absences.171

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Table 26. Items of the Work-Related Burnout and Patient-Related Burnout Subscales of the Copenhagen Burnout Inventory Work Related Burnouta 1. “I felt worn out at the end of the working day.” 2. “I was exhausted at the beginning of my shift at the thought of another day at work.” 3. “I felt that every working hour was tiring.” 4. “I had enough energy for family and friends during leisure time.”* 5. “My work is emotionally exhausting.” 6. “My work frustrated me.” 7. “I felt burned out because of my work.” Patient-Related Burnouta 1. “I found it hard to work with patients.” 2. “I found it frustrating to work with patients.” 3. “It drained my energy to work with patients.” 4. “I felt that I give more than I get back with patients.” 5. “I was tired of working with patients.” 6. “I wondered how long I will be able to continue working with patients.” aResponse scale: Always or almost always, Often, Sometimes, Seldom, Never or almost never *Reverse coded

Figure 10. Confounding Variables for the Relationship between Burnout and Workplace Withdrawal Outcomes

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Figure 11. Confounding Variables for the Relationship between Burnout and Occupational Injury

6.3.4 Analysis

Inclusion criteria for this study consisted of EMTs and paramedics who primarily worked as patient care providers. EMS professionals who work primarily as administrators, supervisors, or in other non-patient care-centered roles were excluded in order to utilize a single analysis population, since patient-related burnout is only applicable for EMS professionals who have provided patient care within the 30 days preceding the survey.

Differences between those who responded to the baseline questionnaire and those who did not were assessed in terms of available demographic information (age, sex, and certification level) and outcome information (turnover, sick days, and injury) obtained from work records at Mecklenburg EMS agency. Categorical variables were compared using Chi-square tests. Given the non-parametric distribution of age among EMS professionals, comparisons of the median age between responders and non-responders were made using the Wilcoxon rank sum test. Similarly, the number of sick days was not

153 expected to be normally distributed and a Wilcoxon rank sum test was used to assess for differences. Differences in the proportion of responders and non-responders who left the agency or who sustained one or more injuries during the study period were compared using Chi-square tests.

Reliability of the work-related and patient-related burnout subscales of the

Copenhagen Burnout Inventory in this population was assessed using Cronbach’s alpha with a value of 0.70 or higher indicating adequate reliability. As burnout scores were expected to follow a non-normal distribution based on prior research, correlation between subscales was measured using Spearman’s rank correlations.24

A two-level variable was created for EMS professionals who were experiencing one or more types of burnout at baseline. To assess for differences based on the type of burnout experienced, a four-level variable was constructed to compare outcomes by burnout status: 1) no burnout 2) work-related burnout alone, 3) patient-related burnout alone, and 4) work-related and patient-related burnout.

For hypothesis 1, the relationship between burnout and turnover was first assessed using Chi-square tests to compare the proportion of EMS professionals who left

Mecklenburg EMS Agency by burnout status. A generalized linear model (GLM) was then used to estimate the crude risk ratios for turnover by burnout status. Adjusted risk ratios were then calculated using a multivariable GLM that controlled for confounding variables outlined in section 6.3.3.3 of this paper. For all GLMs, a log link and robust

Huber-White standard errors were used.

For hypothesis 2, the relationship between burnout status and median number of sickness absences was assessed first using a Kruskal-Wallis test. Since a small number of

154 sickness absences may be expected and typical of any worker, we created a variable to compare providers who missed a high number of sick days versus those who missed a typical number of sick days. Previous work examining the link between burnout and sickness absence used 10 or more days in a 12-month period to denote a high number of sickness absences.24 Ten days was selected as the cut point based on estimates from the

Bureau of Labor Statistics stating that, on average, full-time employees receive between eight and 10 days of paid sick leave per year.172 Because the data used in this analysis only encompassed a six-month period, we considered five or more days missed as a high number of sickness absences. We again used GLMs with a Bernoulli variance, log link, and robust Huber-White standard errors to estimate the crude risk ratio between burnout status at baseline and a higher number of sickness absences. We used a multivariable

GLM to estimate the adjusted risk ratio for a high number of sickness absences by burnout status after controlling for confounding variables outlined in section 6.3.3.3 of this paper.

For hypothesis 3, an outcome variable for occupational injury was created as a dichotomous variable for those who sustained at least one injury during the study period and those who sustained no injuries. A variable for any injury was created since multiple injuries on the same person may not be independent. First, we compared the proportion of

EMS professionals who sustained one or more injuries during the study period by burnout status using Chi-square tests. Next, we used a univariable GLM with a log link,

Bernoulli variance, and robust Huber-White standard errors to estimate the crude risk ratio for sustaining one or more occupational injuries by burnout status. We then

155 constructed a multivariable GLM to assess the risk ratio for injury by burnout exposure, after adjusting for confounding variables outlined in section 6.3.3.3 of this paper.

6.4 Results

A total of 238/425 (response rate=56.0%) EMS professionals responded to the baseline questionnaire. Table 27 displays characteristics of those who responded to the baseline questionnaire and those who did not. A significantly larger proportion of responders were certified at the paramedic level (p<0.01). While the differences were not statistically significant at the alpha=0.05 level, responders also tended to be female

(p=0.08), older (p=0.16), less likely to leave the job (0.07), and less likely to take five or more sick days (p=0.13), compared to non-responders. The proportion of providers who sustained one or more injuries during the study period (p=0.89).

Five respondents were excluded from subsequent analyses as they had not provided any patient care within the past 30 days, leaving 233 EMS professionals in the analysis population (Table 28). Most respondents were male (64.8%) and the median age was 33 (IQR: 28-40). The majority were certified at the paramedic level (64.8%). A total of 4.7% of respondents left Mecklenburg EMS Agency during the study period and

33.5% took five or more sick days. Twenty respondents (8.6%) sustained an occupational injury during the study period. No respondents sustained more than one injury. Due to the small number of outcome events observed during these first six months of observation, multivariable analyses were not conducted to control for confounding variables at this time.

The most common injury location was leg and foot (35.0%), followed by the head and face (30.0%). The most frequent injury type was struck by object (30.0%), followed

156 by overexertion (25.0%). Occupational exposures accounted for 20.0% of injuries. A quarter of injuries (25.0%) were caused by lifting, while another quarter (25.0%) were caused by combative patients. Slightly less than half of injured providers (45.0%) were seen by a medical professional for their injuries (Table 29).

The work-related and patient-related burnout subscales of the Copenhagen

Burnout Inventory demonstrated good reliability in this analysis population (Cronbach’s alpha: 0.90 and 0.90). Spearman’s correlation coefficient between subscales was 0.65 indicating that these variables are related, but are not measuring the exact same construct.

Nearly half of respondents (48.1%) were experiencing at least one type of burnout. Of those experiencing burnout, 49.1% demonstrated work-related burnout alone, while

43.8% demonstrated both work and patient-related burnout. Few demonstrated patient- related burnout alone (7.1%) (See Table 30).

The proportion of providers experiencing one or more types of burnout at baseline who left Mecklenburg EMS Agency was nearly twice the proportion of providers that left who were not experiencing burnout at baseline, though this difference was not statistically significant (6.3% vs. 3.3%, p=0.29). Similarly, a greater proportion of those experiencing burnout at baseline took five or more sick days compared to those not experiencing burnout, but this difference was not statistically significant (37.5% vs.

29.8%, p<0.01). There was no difference in the proportion of EMS professionals who incurred an occupational injury during the study period by burnout status (p=0.52) (See

Table 31).

Next a multi-level variable was used to assess outcomes by the specific type of burnout experienced at baseline. Because of the small number of EMS professionals

157 demonstrating patient-related burnout alone (n=8), these providers were excluded from subsequent analyses by burnout status. A larger proportion of those experiencing work- related burnout only (10.9%) left the agency compared to those experiencing work- related and patient-related burnout (2.0%). The proportion of EMS professionals taking five or more sick days was highest among the work-related burnout only group (41.8%), followed by the work and patient-related burnout group (36.7%). A total of 10.2% of

EMS professionals experiencing both work and patient-related burnout experienced an occupation injury during the study period compared to 7.3% of those experiencing work- related burnout alone and 7.4% of those experiencing no burnout at baseline (Table 32).

Table 33 displays the crude risk ratios for turnover, high sickness absence, and occupational injury by burnout status. The risk of turnover among those experiencing work-related burnout only was 3.30 times that of EMS professionals not experiencing burnout at baseline; however, statistical significance was not reached (RR: 3.30, 95% CI:

0.97-11.26). Similarly, the risk of taking five or more sick days was 41% higher for those experiencing work-related burnout alone compared to those not experiencing burnout, but statistical significance was not reached (RR: 1.41, 95% CI: 0.93-2.13). No difference in the risk of occupational injury was observed by burnout status.

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Table 27. Comparison Responder and Non-Responder Characteristics Responders Non-Responders p-value (N=238) (N=187) Sex 0.08a Female 35.7% (85) 27.8% (52) Male 64.3% (153) 72.2% (135) Age Range 20-62 19-62 Median IQR 33 (28-40) 31 (26-40) 0.16b Certification Level <0.01a EMT 35.2% (83) 50.8% (95) Paramedic 64.8% (153) 49.2% (92) Left job 4.6% (11) 9.1% (12) 0.07a 5+ Sick Days 34.0% (81) 41.2% (77) 0.13a 1+ Injuries 8.4% (20) 8.0% (15) 0.89a aChi-square test bWilcoxon rank sum test

Table 28. Characteristics of EMS Professionals Included in the Analysis Population (N=233) % (n) Sex Female 35.2% (82) Male 64.8% (151) Age Range 20-62 Median IQR 33 (28-40) Certification Level EMT 35.8% (83) Paramedic 64.2% (149) Years of EMS Experience Less than 5 years 32.8% (78) 5 to 15 years 45.8% (109) More than 15 years 21.4% (51) Left job 4.7% (11) 5+ Sick Days 33.5% (78) 1+ Injuries 8.6% (20)

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Table 29. Location, Types, Causes, and Medical Attention of Occupational Injuries among EMS Professionals Included in the Analysis Population (N=20) % (n) Location Leg and foot 35% (7) Head and face 30% (6) Neck and back 20% (4) Hand and fingers 10% (2) Airborne (exposure) 5% (1) Type Struck by 30% (6) Overexertion 25% (5) Slip and fall 25% (5) Exposure 20% (4) Cause Lifting 25% (5) Combative patient 25% (5) Exiting vehicle 15% (3) Vehicle collision 10% (2) Uneven terrain 10% (2) Patient illness 5% (1) Struck by pipe 5% (1) Ice 5% (1) Medical attention sought Yes 45% (9) No 55% (11)

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Table 30. Burnout Prevalence among EMS Professionals at Mecklenburg EMS Agency (N=233) n % Prevalence of Burnout One or more types of burnout 112/233 48.1% Any work-related burnout 104/232 44.8% Any patient-related burnout 57/231 24.7% Both work-related and patient-related burnout 49/232 21.1% Burnout by Type Work-related burnout only 55/112 49.1% Patient-related burnout only 8/112 7.1% Both work-related and patient-related burnout 49/112 43.8%

Table 31. Turnover, Sickness Absence, and Occupational Injury for EMS Professionals Who Experienced Any Burnout Versus Those Who Experienced No Burnout at Baseline Any burnout No burnout p-value (n=112) (n=121) Col % (n) Col % (n) Turnover 6.3% (7) 3.3% (4) 0.29 5+ Sick Days 37.5% (42) 29.8% (36) 0.21 1+ Injuries 9.8% (11) 7.4% (9) 0.52

Table 32. Prevalence of Turnover, Sickness Absence, and Injury by Burnout Status Work- related and Work- patient- related related No burnout burnout only burnout Overall col % (n) col % (n) col % (n) p-value Turnover 4.7% (11) 3.3% (4) 10.9% (6) 2.0% (1) 0.06 5+ Sick Days 33.5% (78) 29.8% (36) 41.8% (23) 36.7% (18) 0.27 1+ Injuries 8.6% (20) 7.4% (9) 7.3% (4) 10.2% (5) 0.81

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Table 33. Risk Ratios for the Relationship between Burnout and Turnover, Sickness Absence, and Occupational Injury Crude RR p-value Turnover No burnout Referent Work-related burnout only 3.30 (0.97-11.26) 0.06 Work-related and patient-related burnout 0.62 (0.07-5.41) 0.66 5+ sick days No burnout Referent Work-related burnout only 1.41 (0.93-2.13) 0.11 Work-related and patient-related burnout 1.23 (0.78-2.13) 0.37 1+ occupational injuries No burnout Referent Work-related burnout only 0.98 (0.31-3.05) 0.97 Work-related and patient-related burnout 1.37 (0.48-3.90) 0.55

6.5 Discussion

This study evaluated the relationship between burnout and variables that could negatively impact the EMS workforce. Though, not statistically significant, there was a trend towards significance for the relationship of burnout with turnover and sickness absence. Meanwhile, this study did not identify a clear relationship between burnout and occupational injury. These findings add to the literature by demonstrating a prospective association between burnout and risk of turnover and sickness absence with verified work records, while other work has relied on self-reported outcomes.24,79

The findings of this study support the association between burnout and sickness absence and turnover intention found in previous cross-sectional work conducted among nationally-certified EMS professionals.24 In the previous study, work-related burnout was associated with a three-fold increase in odds of intending to leave an EMS job within the next 12 months (OR: 3.37, 95% CI: 2.67-4.26).24 Our study found that the risk of leaving the agency was very similar (RR: 3.30, 95% CI: 0.97-11.26). The similarity in the results

162 from self-reported intent to leave an EMS job to the results of this study using actual employment records suggests that self-reported data are valuable for assessing this relationship.

Previous work showed that EMS professionals experiencing work-related burnout were at greater odds of reporting 10 or more sickness absences in the past year.24 This study was limited as the exposure of interest was measured after the outcomes of interest and due to the self-reported nature of the data. The measure of effect observed in this study (RR: 1.41, 95% CI: 0.93-2.13) was slightly smaller than the associated detected in previous work (OR: 2.30, 95% CI: 1.39-3.83).24 Nevertheless, the time periods used (six months versus one year) and the cut point used to classify high versus normal sickness absences (five or more days versus 10 or more days) were different and may account for the difference in effect size. The prospective association between burnout and sickness absence in this study demonstrates temporality between the exposure and the outcome and lends some support for the argument that burnout causes providers to take sick days.

No clear relationship was identified between burnout and occupational injury in this study. The small number of injuries observed overall may have limited the ability to detect a difference. It is also possible that other injuries occurred and were not reported to the company. While Mecklenburg EMS Agency has a policy that employees are to report all injuries occurring on the job, whether requiring medical attention or not, it is likely that employees tend to underreport less severe injuries. Previous work has shown that underreporting is particularly common with musculoskeletal injury and needlestick injury, which are two of the most commonly incurred injury types in EMS.29 Further, if an injury occurred due to failure to use proper safety procedures, the employee may be

163 less likely to report the injury. If employees experiencing burnout were more likely to omit proper safety procedures, incurred more injuries that were less severe in nature and were less likely to report these injuries, a differential reporting bias could have influenced the results of this study. The lack of a strong relationship between burnout and injury in this study does not mean that a link does not exist.

6.5.1 Conservation of Resources Model

While statistical significance was not reached, the results of this study suggest that providers experiencing the exhaustion central to burnout are more likely to retreat from work either through sickness absences or leaving the job. Thus Hypothesis 1

(burnout is associated with greater risk of leaving the profession) and Hypothesis 2

(burnout is associated with a greater number of sickness absences) were partially supported, though a larger number of events is needed to detect statistically significant differences.

This study did not find support for Hypothesis 3 (burnout is associated with higher risk of occupational injury). A variety of factors may have contributed to the failure to find support for this hypothesis in this study. Previous work found a relationship between burnout and injury mediated through workarounds. It is possible that some injuries observed in this study were not affected by workarounds (e.g., slip and fall on ice) and could obscure the effect between burnout and injury. The conservation of resources theory suggests that employees experiencing burnout will be less likely to engage in behaviors that are perceived as discretionary or non-essential.27 Thus, it is also possible that employees experiencing burnout would conserve resources by not investing the effort to file an injury report for a minor injury that required no medical attention.

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6.5.2 Limitations

The use of a single EMS agency may limit the generalizability of the findings of this study. Mecklenburg EMS is a county-based agency that operates in an urban setting.

It is possible that the relationship between burnout and sickness absences could differ at other agencies with different policies regarding paid sick leave. The risk of leaving an

EMS job may also be different in rural settings where there are fewer EMS agencies.

Further, the use of a single agency resulted in a small sample size and small number of events recorded for turnover and occupational injury limited the ability to detect meaningful differences by burnout status.

The small number of observed outcome events limited the ability to control for important potential confounding variables that could potentially mask the true underlying relationships between burnout and the outcomes of interest. For example, it is possible that paramedics are in higher demand in the Mecklenburg area and providers certified at this level are able to move between jobs more easily. In this case, paramedics may be more likely to leave one EMS job for another. Paramedics are also more likely to experience burnout and were more likely to participate in this study. It is possible that the association observed between burnout and increased turnover could be influenced by certification level and is not a direct relationship between burnout and turnover.

Nevertheless, previous work at the individual level that did control for certification level, supports the relationship between increased burnout and increased turnover observed in the unadjusted analysis from this study.24

Another potential limitation stemming from the use of a single agency is that

EMS professionals may have had concerns that their information would not be kept

165 confidential and that their employer might be able to see the results. The survey e-mail invitation advised participants that their answers would be kept confidential and that

Mecklenburg EMS Agency would not have access to individual responses; however, it is possible that respondents were skeptical of the confidentiality of their responses and provided answers that would be more acceptable to the employer. For example, respondents may have been reluctant to agree with the phrase, “My work frustrated me”, which is an item on the Copenhagen Burnout Inventory. This may have resulted in underreporting of burnout, making it less likely to detect a difference in the study outcomes by burnout status.

One of the limitations stemming from the analysis strategy undertaken is opportunity bias for those who left the job. EMS professionals who left the job were no longer at risk of incurring sickness absences or injury. Time-to-event analysis, such as a

Poisson regression or negative binomial modelling approach, could be used to overcome this limitation; however, this type of analysis assumes that the burnout start time is the same for everyone (baseline). In reality, EMS professionals may have been experiencing burnout and therefore been at risk for the outcomes of interest for differing periods of time would not be reflected in the analysis. Further, the number of EMS professionals who left the agency during the observation period for this analysis was low (N=11) and would not likely have a large impact on the direction or magnitude of the findings.

Response bias represents another potential limitation to the findings of this study.

It is possible that EMS professionals experiencing burnout would be more interested in the topic and would be more likely to respond to the baseline questionnaire. This would result in a higher prevalence of burnout in the study analysis population than in the target

166 population. The reverse is also plausible, in that EMS professionals experiencing burnout would be less likely to expend additional resources to respond to a voluntary survey. This explanation may be more plausible according to the conservation of resources theory, which suggests that providers experiencing burnout will be less likely to engage in additional non-essential behaviors.27 The non-responder analysis also supports this explanation, since a larger proportion of those who did not respond to the survey demonstrated the outcomes associated with burnout (i.e., left the agency or took five or more sick day), though these differences between responders and non-responders were only marginally significant. If EMS professionals experiencing burnout were less likely to respond, the prevalence of burnout observed in the analysis population would be conservative. Nonetheless, the focus of this project was not on estimating the prevalence of burnout, rather this study centered on the relationships between burnout and factors that could negatively impact the EMS workforce. We do not expect that the relationships between burnout and the outcomes of interest would be different between responders and non-responders.

Finally, the decision to dichotomize the burnout subscales for work and patient- related burnout may also represent a limitation to this study. Participants were classified as demonstrating burnout in the domain if the average composite score in the subscale was 50 or higher. This cut point was selected based on guidelines by the authors of the tool and makes comparisons between previous studies feasible.24,114 However, the use of a dichotomous cut point means that individuals who have similar scores, but fall on opposite sides of the cut point are treated as very different in terms of burnout.157

Nevertheless, the ordinal nature of how the data were collected limits the use of the

167 composite score as a continuous variable. Treating the variable as a continuous measure assumes that the points are equal interval, meaning that the distance between sometimes and seldom is the same as the distance between often and always/almost always. Since the equal interval assumption may not be true, creating meaningful categories represents a more sound analysis strategy.156

6.5.3 Implications and Future Directions

The findings of this study regarding the potential impact of burnout on the health and stability of the EMS workforce are concerning. If left unchecked, burnout may have serious implications for the well-being of EMS providers, limiting their ability to be present and engaged at work, or even cutting their careers short. Turnover is costly to organizations and workforce shortages could negatively impact patient care. Reducing burnout in this population may improve retention of EMS professionals and reduce workforce shortages. Future work is needed to explore interventions aimed to reduce burnout among EMS professionals and determine whether turnover and sickness absence are reduced.

When EMS professionals experiencing burnout abruptly leave a job or take unscheduled sickness absences, vacant shifts are created that must be filled immediately to meet demand for emergency care. Many agencies implement mandatory overtime policies to meet these needs. Mandatory overtime may entail calling an EMS professional on his or her day off and requiring that he or she come into work or requiring an employee to stay later than his or her shift’s scheduled end time.173 The increased job demands and potential dissatisfaction generated from mandatory overtime could in turn lead to more burnout and create a spiral effect whereby employees experiencing burnout

168 leave the agency, remaining employees are forced to work increased hours, which generates burnout among these employees and creates more vacancies. Future work should examine the impact of burnout on EMS professionals at the agency who are required to cover vacant shifts and work additional hours.

While no clear relationship was identified between burnout and injury in this study, injury remains an important concern for the EMS workforce and warrants further investigation. Further research is needed to examine preventable versus non-preventable injuries and their association with burnout. A preventable injury is one that could have been avoided if proper safety protocols had been used.174 The small number of injuries overall in this study prevented a subgroup analysis for preventable injury; however, given that burnout is associated with workarounds and shortcuts, there may be a relationship between this condition and preventable injuries that resulted from not adhering to safety protocols.27 Future research involving multiple EMS agencies is needed to examine the relationship between burnout and preventable injuries in EMS.

6.6 Conclusions

While studies of burnout in healthcare have traditionally focused on the burden and etiology, this study explored the potential impact of burnout on EMS professionals.

In this prospective study, there was a trend towards significance for the association between burnout and sickness absence and turnover; however, no relationship was observed between burnout and occupational injury. This study suggests that EMS professionals experiencing burnout are more likely to retreat from work through turnover or sickness absence, which could negatively impact the stability of the workforce.

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Chapter 7. Discussion

Providing prehospital care involves high physical, mental, and emotional demands that may place EMS professionals at high risk for occupational burnout. The job demands-resources theory postulates that burnout results when job demands exceed job resources for an extended period of time.83 Since job demands and resources are likely similar among individuals working at the same EMS agency, burnout levels may be similar among employees at the same agency as well. Making changes to job demands and resources at the agency level could then have a large impact on the burden of burnout. Burnout has been linked to factors that negatively impact the workforce, including sickness absence and turnover; however, previous work has been cross- sectional in nature.24 Additionally, burnout has been associated with safety workarounds, which are associated with increased risk for occupational injury.27 The potential link between burnout and occupational injury represents an important workforce concern in the prehospital setting, as previous research has shown that EMS professionals are at greater risk for fatal and non-fatal injuries compared to other occupations.29

The overall goal of this work was to provide evidence for key EMS stakeholders, including leaders at the local, state, and federal levels, to design interventions aimed to prevent and mitigate burnout among EMS professionals. Key findings are presented briefly here, followed by a discussion of the implications, strengths, and limitations of this research.

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7.1 Summary of Findings

Our research is unique in that burnout was examined at the level of the EMS agency. Most research has focused on this condition at the level of the individual EMS professional.24,77-79. By surveying EMS professionals licensed within a single state and aggregating responses using agency rosters, we quantified the variation in burnout levels between EMS agencies and identified agency characteristics associated with higher levels of burnout (Specific Aim 1). We also used the statewide survey of EMS professionals to assess the magnitude of the association between specific job demands and resources and burnout after taking into account clustering at the EMS agency level (Specific Aim 2).

Finally, we conducted a prospective cohort study among EMS professionals at a large county-based agency to evaluate the relationship between burnout and the incidence of factors that may negatively impact the EMS workforce including turnover, sickness absence and occupational injury (Specific Aim 3).

7.1.1 Aim 1 Findings

The cross-sectional evaluation of burnout at EMS agencies in South Carolina showed substantial variation in the prevalence of this condition across agencies. Variation in work-related burnout was more pronounced and overall, the prevalence of patient- related burnout was lower. Agency characteristics associated with work-related burnout included the annual call volume, number of EMS employees, and vehicle count.

Meanwhile, only agency annual call volume and number of employees were significantly associated with patient-related burnout. A marginally significant association was seen between patient-related burnout and vehicle count.

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7.1.2 Aim 2 Findings

Findings from the evaluation of specific job characteristics associated with burnout indicate that, in general, increased job demands are associated with greater odds of burnout while increased job resources are associated with reduced odds of burnout.

Important job demands related to both work and patient-related burnout in EMS included time pressure, posting in an emergency vehicle, and elements of the base environment

(e.g., having a place to eat, shower, or relax). Job resources significantly related to work and patient-related burnout included performance feedback, paid uniforms, tuition assistance, pay, job control, a participatory environment, respect from managers and co- workers, adequate orientation, and adequate training.

Evaluation of job demands and resources in aggregate revealed that compared to those in a favorable working situation with low job demands and high job resources, providers with high job demands and low job resources demonstrated over a nine-fold increase in odds of both work and patient-related burnout.

7.1.3 Aim 3 Findings

The results from the prospective evaluation of a cohort of EMS professionals showed that few providers experienced patient-related burnout alone. While statistically significant relationships were not detected with the available data at six months into the study, there was a trend towards significance for burnout and the risk of turnover.

Similarly, there was a trend towards significance for burnout and increased sickness absence. The results of this study did not suggest a clear significant relationship between burnout and occupational injury, potentially due to the overall small number of events observed during the study period.

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7.2 Theoretical Framework

This research was guided by the job demands-resources model and the conservation of resources theory.83,84 The job demands-resources model states that burnout occurs due to a prolonged imbalance where job demands exceed job resources. In

Aim 1, we hypothesized that EMS agency characteristics would be associated with the demands and resources present and therefore be related to the level of burnout at the agency level. We found some evidence for this hypothesis as agency type and variables related to agency size (call volume, number of EMS employees, vehicle count) were associated with the median prevalence of one or more types of burnout at the agency level.

In Aim 2, we sought to quantify the relationship between specific job characteristics and burnout. One of the key advantages of using the job demands- resources model to guide this work is that the model does not prescribe specific job demands and resources that are most important in the relationship with burnout. Instead, this model acknowledges that the specific job demands and resources that have the strongest relationship with burnout are likely to vary from one occupation to another. In the second study of this work we explored various job demands and resources that are common in the field of EMS. The direction of the associations followed the job demands resources model in that greater job demands were associated with higher odds of burnout and greater job resources were associated with reduced odds of burnout. When composite measures of high and low job demands and resources were considered, again the findings followed suit with the job demands-resources model. EMS professionals experiencing high job demands and low job resources demonstrated significantly greater odds of both

173 work and patient-related burnout compared to their counterparts experiencing low job demands and high job resources. Similar to findings among a population of Finnish teachers, we saw that having high job resources to meet high job demands attenuated the magnitude of the relationship with burnout.85

In Aim 3, we used the conservation of resources theory to explore potential negative outcomes of burnout in EMS. The conservation of resources theory states that individuals experiencing the physical and mental energetic depletion characteristic of burnout will be more cautious about investing future energetic resources. We hypothesized that EMS professionals experiencing burnout may choose to conserve resources by retreating from work either through sickness absence or by leaving the job.

While the differences observed after six months of data collection were not statistically significant, there was a trend towards significance for the relationship between burnout and increased sickness absence and turnover. Rather than retreat from work, we hypothesized that some EMS professionals experiencing burnout would choose to stay on the job. To conserve energetic resources, these EMS professionals may not engage in behaviors that they see as non-essential, which could include adherence to safety protocols. We hypothesized that burnout would be associated with workarounds or shortcuts and lead to higher rates of occupational injury. In this study a small number of injuries was observed overall and no relationship was observed between burnout and occupational injury. Nevertheless, the lack of a significant relationship between burnout and injury in this study does not provide evidence against the conservation of resources theory. It is plausible that some injuries in this study were the result of bad luck and did not occur due to improper adherence to safety protocols. We were unable to measure

174 workarounds and shortcuts to determine which, if any, injuries were the result of not adhering to agency safety policies. Further work is needed to determine whether or not

EMS professionals experiencing burnout conserve energy by engaging in safety- compromising behaviors that could lead to injury.

7.3 Implications

High turnover is an important concern in EMS that costs EMS agencies an estimated median of over $70,000 annually.117 Key informants for the EMS Workforce for the 21st Century report highlighted the need to reduce worker burnout to improve retention of the EMS workforce.118 The results of this work lend some support for this need as there was a trend towards significance for the relationship between burnout and increased incidence of turnover. Additionally, our work found a significant association between burnout and increased incidence of sickness absence. Sickness absence has not received as much attention from EMS stakeholders as a variable that negatively impacts the EMS workforce; however, the potential negative consequences of sickness absence may be far-reaching. Shifts left vacant due to unplanned sickness absence must be filled to meet the public’s demand for emergency response. For this reason, some EMS agencies have resorted to mandatory overtime policies requiring an EMS professional to work additional hours or shifts.173 The increased job demands imposed on EMS professionals forced to cover shifts left vacant by employees experiencing burnout may begin to experience burnout themselves. In this way, if left unchecked, burnout could have major negative consequences on retention of healthy employees and could negatively impact the EMS agency’s ability to meet public demand for services.

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Efforts to reduce burnout have typically followed one of two approaches, making changes at the individual level, or making changes at the level of the workplace organization.48 Across professions, most existing work has focused on the individual level due to the belief that is easier to change the individual and that burnout is an individual problem.175 Nevertheless, results from this research suggest that a multifaceted approach is likely to be more effective for reducing burnout in EMS. Burnout prevalence varied substantially between EMS agencies and was associated with specific job characteristics. Reducing job demands or increasing job resources at the agency level is likely to impact a larger number of EMS professionals at once. For example, an EMS agency supervisor may decide to implement a structured system for delivering timely performance feedback that may not require substantial financial investment, but could have a significant positive impact on burnout reduction. Creating mechanisms for employees to submit feedback to agency leadership could also represent a cost-effective strategy for lowering burnout through the addition of a job resource. Acknowledging the importance of job resources and recognizing burnout as an agency-level construct frees management from blaming the individual and sets the stage for more proactive strategies to prevent burnout.95

7.4 Strengths and Limitations

Detailed discussions of the strengths and limitations of each aim are presented in

Chapters 4 through 6. A major strength of this project was the focus on a defined EMS population covering a variety of EMS agencies in differing practice settings for Aims 1 and 2. A major strength of Aim 3 was the use of work records to prospectively assess turnover, sickness absence, and occupational injury. Measuring burnout with the

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Copenhagen Burnout Inventory and categorizing the presence of burnout in the same manner as previous work facilitates comparisons between studies.

An important study limitation is the potential for response bias. The response rate to the questionnaire used for Aims 1 and 2 was 18.5%. Though a non-responder questionnaire was administered, participation in this survey was also low. There is a risk that those who did not participate experienced burnout at a higher or lower rate than those who did participate. The non-response analysis suggested that there was no difference in the prevalence of work-related burnout between responders and non-responders.

However, it is possible that our prevalence estimates are inflated if EMS professionals exhibiting burnout were more likely to share their experience through the questionnaire.

For Specific Aim 3, the response rate for the baseline questionnaire was higher at 56.0%.

Nevertheless, the potential for response bias exists and non-responder analysis revealed that females and providers certified at the paramedic level were more likely to respond.

Additionally, the small sample size may have limited the ability to detect differences in outcomes by burnout status when differences may have truly existed.

7.5 Conclusions

In conclusion, this research evaluated the burden and potential impact of burnout at the EMS agency level. Burnout in EMS represents an important concern that negatively impacts EMS professionals, agencies, and could ultimately affect patients who require emergency care. Negative outcomes associated with burnout included increased sickness absence and turnover, which may leave vacant shifts that remaining EMS employees must fill. The increased job demands associated with working overtime to fill vacant shifts could in turn generate more burnout. Further, EMS professionals

177 experiencing burnout who remain on the job may conserve energetic resources by not engaging in behaviors viewed as discretionary, which could have a negative impact on the quality of care and safety. The prevalence of burnout varied widely between EMS agencies located within a single state, which suggests that agency-level variables may affect the development of burnout and a multi-level approach is needed to combat this condition. Increased job demands were associated with increased odds of burnout, though having increased job resources to meet these demands reduced the magnitude of the relationship between demands and burnout. Specific job resources that could be modified at the level of the EMS agency that may have a substantial impact on burnout were identified, including the provision of performance feedback and creation of a participatory work environment.

178

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and supervisor support on job burnout and job satisfaction. J Adv Manag Res.

2016;13(1):4-22.

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Emergency Medical Services Profession and Characteristics Associated with

Intent to Return to Practice. Prehosp Emerg Care. 2018;22(1):28-33.

145. Rothman KJ, Greenland S, Lash TL. Modern Epidemiology. 2008.

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Medical Technician-Paramedic. http://www.caahep.org/content.aspx?id=39.

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EMS agencies. J Rural Health. 2003;19(4):492-496.

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Someone Had Told Me…”: Lessons From Rural Providers. J Rural Health.

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stress in emergency medical services: a qualitative study. Stress and Health.

2009;25(2):139-149.

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personnel: predictors of health symptoms. Occup Environ Med. 2003;60 Suppl

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Appendix A. Survey Instrument for Specific Aims 1 & 2

Welcome Page

Thank you for agreeing to participate in this study! Results of this survey will help us to better understand the challenges faced by the EMS workforce.

The survey will take approximately 10 to 15 minutes. Your participation in this research project is entirely voluntary. The NREMT does not mandate/require participation in this project, and as such there are no penalties associated with not participating or discontinuing participation at any time. You may refuse to answer any question by selecting 'Next' to move to the next question. Additionally, you can quit the survey at any time. Further, there are no foreseeable risks in participation.

Your privacy is important to us, and your responses will be kept absolutely confidential. Only data summarizing groups of participants will be reported. By clicking 'Next' below you are consenting to participate in the study. If you have any questions or want to obtain more information about this very important project, please contact the NREMT Research Department at 614-888-4484 or via email at [email protected]. If you have concerns or questions about your rights as a participant, you can contact the Chair of AIR’s Institutional Review Board (which is responsible for the protection of study participants) at [email protected] or toll-free at 1-800-634-0797.

Please click 'Next' to continue.

1. To go back to a previous question, use the back arrow at the bottom of the page. Do NOT use your browser's back arrow.

2. If you want to take a break, you can save your answers using the save button at the top of your screen. You can return to the survey by clicking on the URL in the email invitation you will receive.

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Page exit logic: Skip / Disqualify Logic IF: ((Question "At what level are you currently practicing as an EMS professional?" #1 is one of the following answers ("None") OR Question "How many years have you worked as an EMS professional?" #2 is one of the following answers ("I have never worked as an EMS professional")) OR Question "For how many different EMS agencies/organizations do you currently perform EMS work?" #3 is one of the following answers ("0")) THEN: Jump to page 12 - Provider Demographic Characteristics

1) At what level are you currently practicing as an EMS professional? ( ) None ( ) Emergency Medical Responder ( ) Emergency Medical Technician (Basic) ( ) Emergency Medical Technician - Intermediate. The Emergency Medical Technician - Intermediate level should only be used in states in which individuals are licensed at this level. As states transition to the National EMS Scope of Practice Model, it is anticipated that there will be no new Emergency Medical Technician - Intermediate licenses granted. ( ) Advanced Emergency Medical Technician. The advanced Emergency Medical Technician level should only be used in states in which individuals are licensed at this level. ( ) Paramedic

Logic: Show/hide trigger exists. Hidden unless: Question "At what level are you currently practicing as an EMS professional?" #1 is one of the following answers ("Emergency Medical Responder","Emergency Medical Technician (Basic)","Emergency Medical Technician - Intermediate.","Advanced Emergency Medical Technician","Paramedic")

2) How many years have you worked as an EMS professional? ( ) I have never worked as an EMS professional ( ) Less than one year ( ) 1-2 years ( ) 3-4 years ( ) 5-7 years ( ) 8-10 years ( ) 11-15 years ( ) 16-20 years ( ) 21 or more years

Logic: Show/hide trigger exists. Hidden unless: Question "How many years have you worked as an EMS professional?" #2 is one of the following answers ("Less than one year","1-2 years","3-4 years","5-7 years","8-10 years","11-15 years","16-20 years","21 or more years")

3) For how many different EMS agencies/organizations do you currently perform EMS work?

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( ) 0 ( ) 1 ( ) 2 or more

Main EMS Agency Definition

The following questions ask about your main EMS agency. If you work for more than one EMS agency, please consider the agency or organization for which you responded to the most calls (emergency or non-emergency) in the past 30 days as your main EMS agency.

4) Please select your main EMS agency [Drop Down List of SC EMS Agencies]

5) How long have you been employed/volunteered at your main EMS agency? ( ) Less than one year ( ) 1-2 years ( ) 3-4 years ( ) 5-7 years ( ) 8-10 years ( ) 11-15 years ( ) 16-20 years ( ) More than 20 years

6) Which of the following best describes your current employment status at your main EMS agency? (Volunteers who work fewer than 36 hours per week, please select "part-time") ( ) Full-time ( ) Part-time

7) Which of the following best describes your primary role at your main EMS agency? ( ) Patient Care Provider - A person whose primary role is the provision of EMS services to patients. ( ) Educator - A person whose primary role is instructing individuals enrolled in an approved or accredited EMS training course or providing continuing education required for maintenance of licensure. ( ) Preceptor - A person whose primary role is training individuals enrolled in an approved or accredited EMS training course in a clinical setting. ( ) Dispatcher/Call Taker - A person whose primary role is EMS communications. ( ) Administrator/Manager - A person whose primary role is the management and direction of an organization providing EMS services. ( ) First-line Supervisor - A person whose primary role is the direct supervision of individuals providing EMS services. ( ) Other - A person whose primary EMS role at their main job is not listed above (please specify).: ______

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8) Which of the following best describes your main EMS agency? ( ) Hospital - refers to EMS agencies that are under the direct control of a hospital, regardless of the type of organization that runs the hospital. ( ) Fire Department - an organization from which fire and EMS services are provided, regardless of the type of organization that runs the Fire Department. Volunteer fire departments should be included here. ( ) Tribal - are operated by a federally recognized Indian or Alaska Native Tribe. ( ) Military - are operated by one of the U.S. Armed Forces and staffed by active duty personnel. ( ) Government, Non-Fire Department - are operated directly by a federal, state, county, or local government entity other than the U.S. Armed Forces. ( ) Private - are operated under the direct control of a for-profit or not-for-profit organization other than a hospital. Volunteer rescue squads that are operated independently of a fire department should be included here. ( ) Air Medical - an organization which provides air ambulance services, regardless of the type of organization which runs the air ambulance service. ( ) Other - Please specify: ______

9) Which of the following best describes the primary type of service provided by your main EMS agency? ( ) Primarily 911 response with or without transport capability - Immediate response to an incident location, regardless of method of notification (for example, 911, direct dial, walk-in, flagging down). ( ) Primarily medical transport (convalescent) - Transport of a patient from one health facility to another. ( ) Equal mix of 911 and medical transport (convalescent) ( ) Clinical services - Provision of clinical services in an non-ambulance clinical setting such as emergency department, medical office, or dialysis clinic. ( ) Mobile Integrated Healthcare & Community Paramedicine - Provision of clinical services in an out-of-hospital community setting. ( ) Other - Please specify: ______

10) Volunteers are licensed EMS workers who receive nominal or no compensation for their provision of EMS services at the agency. At your main EMS agency, are you a volunteer EMS provider? ( ) Yes ( ) No

Logic: Hidden unless: Question "For how many different EMS agencies/organizations do you currently perform EMS work?" #3 is one of the following answers ("2 or more")

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11) At any of your other EMS agencies, are you a volunteer EMS provider? ( ) Yes ( ) No

12) At your main EMS agency, have you provided any patient care in the past 4 weeks? ( ) Yes ( ) No

Work-Related Burnout

13) Please read over each of the next statements and indicate how often the statement applied to you over the past 4 weeks.

Always Never or or Often Sometimes Seldom almost almost always never

I felt worn out at the ( ) ( ) ( ) ( ) ( ) end of my work day.

I was exhausted at the ( ) ( ) ( ) ( ) ( ) beginning of my shift at the thought of another day at work.

I felt that every ( ) ( ) ( ) ( ) ( ) working hour was tiring

I had enough energy ( ) ( ) ( ) ( ) ( ) for family and friends during leisure time.

My work was ( ) ( ) ( ) ( ) ( ) emotionally exhausting.

My work frustrated ( ) ( ) ( ) ( ) ( ) me.

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I felt burned out ( ) ( ) ( ) ( ) ( ) because of my work.

Patient-Related Burnout Logic: Hidden unless: Question "At your main EMS agency, have you provided any patient care in the past 4 weeks?" #12 is one of the following answers ("Yes")

14) Please read over each of the next statements and indicate how often the statement applied to you over the past 4 weeks.

Always Never or or Often Sometimes Seldom almost almost always never

I found it hard to ( ) ( ) ( ) ( ) ( ) work with patients.

It drained my ( ) ( ) ( ) ( ) ( ) energy to work with patients.

I felt that I give ( ) ( ) ( ) ( ) ( ) more than I get back with patients.

I was tired of ( ) ( ) ( ) ( ) ( ) working with patients.

I wondered how ( ) ( ) ( ) ( ) ( ) long I will be able to continue working with patients.

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15) At your main EMS agency, do you have a dedicated space to:

Yes No

Sleep ( ) ( )

Shower ( ) ( )

Eat/prepare food ( ) ( )

Store belongings ( ) ( )

Exercise ( ) ( )

Relax (e.g., sit, read, watch TV, play video games) ( ) ( )

16) At your main EMS agency, how often do you post in your emergency vehicle while awaiting calls? ( ) Always/almost always ( ) Often ( ) Sometimes ( ) Seldom ( ) Never/almost never

17) With regards to your main EMS agency, please indicate how much you agree or disagree with the following statements:

Strongly Slightly Slightly Strongly agree agree disagree disagree

EMS personnel have to ( ) ( ) ( ) ( ) hurry between runs because they have too much work to do.

18) In the past 4 weeks, how many overnight shifts have you worked at your main EMS job? ( ) None ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6

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( ) 7 ( ) 8 ( ) 9 ( ) 10 ( ) 11 ( ) 12 ( ) More than 12

19) In the past 4 weeks, how many shifts have you worked that were 24 hours or longer at your main EMS job? ( ) None ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) 6 ( ) 7 ( ) 9 ( ) 10 ( ) 11 ( ) 12 ( ) More than 12

20) Thinking about your main EMS job, please indicate how much you agree or disagree with the following statements:

Strongly Slightly Slightly Strongly agree agree disagree disagree

I receive appropriate feedback ( ) ( ) ( ) ( ) about my performance from my immediate supervisor.

I receive appropriate feedback ( ) ( ) ( ) ( ) about my performance from my medical director.

I depend on overtime pay to ( ) ( ) ( ) ( ) make ends meet.

I have freedom to decide how I ( ) ( ) ( ) ( ) do my work.

207

I have sufficient control over ( ) ( ) ( ) ( ) my work schedule.

21) Thinking about your main EMS agency, please indicate how much you agree or disagree with the following statements:

Strongly Slightly Slightly Strongly agree agree disagree disagree

The management of this EMS ( ) ( ) ( ) ( ) agency supports my daily efforts.

My immediate supervisors treat ( ) ( ) ( ) ( ) me with respect.

My co-workers treat me with ( ) ( ) ( ) ( ) respect.

EMS personnel input is well- ( ) ( ) ( ) ( ) received at my main EMS agency.

Staff who are new to this ( ) ( ) ( ) ( ) agency receive adequate orientation.

Staff get the training they need ( ) ( ) ( ) ( ) in this agency.

22) Please indicate whether or not you receive each of the following benefits you receive from your main EMS agency?

Yes No

Paid vacation ( ) ( )

Paid sick leave ( ) ( )

Health insurance ( ) ( )

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Dental insurance ( ) ( )

Vision insurance ( ) ( )

Uniform allowance ( ) ( )

Tuition assistance ( ) ( )

Profit sharing ( ) ( )

Stock options ( ) ( )

Retirement plan ( ) ( )

23) How likely is it that you'll leave your current main EMS job within the next 12 months? ( ) Definitely will not leave ( ) Probably will not leave ( ) Probably will leave ( ) Definitely will leave

24) How likely is it that you'll leave EMS within the next 12 months? ( ) Definitely will not leave ( ) Probably will not leave ( ) Probably will leave ( ) Definitely will leave

25) In the past 12 months, have you been injured during a shift? ( ) Yes ( ) No

Logic: Hidden unless: Question "In the past 12 months, have you been injured during a shift?" #25 is one of the following answers ("Yes") 26) Did you report the injury to your employer? ( ) Yes ( ) No

27) In general, how would you describe your health? ( ) Excellent ( ) Very good ( ) Good ( ) Fair ( ) Poor

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Validation: Min = 0 Max = 365 Must be numeric

28) During the past 12 months, how many days have you been absent from your EMS job(s) due to personal illness. Please enter whole numbers only. If none, enter "0". (Please do not include days you missed due to work-related illness/injury or the illness of a child or family member). ______

The following section asks questions about you. This information will be used for classification purposes only and the data you share will not be used to personally identify you. You may choose not to answer any question by clicking 'Next.'

29) In what year were you born? ______

30) What is your sex? ( ) Male ( ) Female

31) Which of the following best describes your current marital status? ( ) Married ( ) Divorced ( ) Widowed ( ) Separated ( ) Never been married ( ) A member of an unmarried couple

32) How many children younger than 18 years of age live in your household? ( ) None ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) More than 5

Thank You!

Thank you for participating in this important EMS research project!

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Appendix B. Pre-notification E-mail from Chief of the South Carolina Bureau of

EMS for Specific Aims 1 & 2

From: Rob Wronski Subject: Research Collaboration with NREMT / SC BEMS / The Ohio State University Addressing EMS Burnout in South Carolina

Dear EMS Colleagues,

The SC Bureau of EMS is excited to announce the rollout of a research collaboration with the National Registry of EMTs (NREMT) and The Ohio State University. Remle Crowe, an EMS Research Fellow at the NREMT and PhD student at Ohio State, is conducting a study related to burnout as part of her dissertation work and needs your help. Later this week, you will receive an email from the NREMT Research Team with an invitation to participate in a 10-minute online survey. We ask that you please take the time to participate as the findings of this study may lead to important interventions to improve the health and well-being of the EMS workforce in the future. This study's results and its timing will tie in directly with the work that the SC EMS Association and a host of other collaborators are doing and will assist us in our quest to train and retain EMS personnel in SC at all levels.

The following link contains a flyer with additional information about the study: http://bit.ly/SCResearchFlyer

You will receive emails in the near future with links to the study and its questions and we ask that each and every one of you take the time to participate in this extremely valuable project. Several randomly awarded incentives will be announced for those that participate.

Yours in Service,

Rob Wronski Chief, Bureau of EMS and Trauma SC DHEC

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Appendix C. Pre-notification Flyer for Specific Aims 1 & 2

212

213

Appendix D. E-mail Invitation to Complete Questionnaire for Specific Aims 1 & 2

From: NREMT Research Team Subject: SC EMS Research Study

Dear EMS Colleague,

I would like to personally invite you to participate in a research survey being conducted by the NREMT and the South Carolina Bureau of EMS. I will be using the data from this survey as part of my dissertation work at The Ohio State University and greatly appreciate your help.

You have been selected to provide your expert opinions as a South Carolina EMS professional. Even if you are not working in EMS, your participation is important. This survey should take about 10 minutes to complete. Your participation in this research project is entirely voluntary and there are no penalties associated with not participating or discontinuing participation at any time. Further, there are no foreseeable risks in participation.

Your privacy is important to us, and your responses will be kept absolutely confidential. Only data summarizing groups of participants will be reported. If you have any questions, or want to obtain more information about this very important project, please contact the NREMT Research Department at 614-888-4484 or via email at [email protected]. If you have concerns or questions about your rights as a participant, you can contact the Chair of AIR's Institutional Review Board at 1-800-634-0797 or viaemail at [email protected].

Individuals who choose to participate will be entered in a drawing to win 1 of 10 Amazon gift cards worth $100 each.

The time you spend answering this questionnaire can have a real impact on our profession.

Click Here to Start the Survey

Thank you,

Remle Crowe and the NREMT Research Team

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Appendix E. E-mail Invitation to Complete Abbreviated Non-Responder

Questionnaire for Specific Aims 1 & 2

From: NREMT Research Team Subject: Shortened EMS Research Study. We still need your help!

Hello!

In November, we sent you an e-mail inviting you to complete an EMS research survey as part of a collaboration with researchers at the National Registry of EMTs and The Ohio State University. In order for this project to be a success and to better understand EMS providers and the EMS profession, we still need your input.

We recognize that you are very busy. So, we have shortened the survey. We greatly appreciate your time and have shortened this survey to take less than 5 minutes.

All your responses will be kept confidential. Only data summarizing groups of participants will be reported. Feel free to refuse to answer any question that you don't want to answer. Your participation is voluntary and has no impact on your National EMS Certification. If you have any questions or want to obtain more information about this research project, please contact the NREMT Research Department at 614-888-4484 or via email at [email protected]. If you have concerns or questions about your rights as a participant, you can contact the chair of AIR's Institutional Review Board at 1-800-634- 0797 or via e-mail at [email protected] .

Please Click Here to Start the Survey

Thank you again for your time and support of this EMS research project!

Respectfully,

Remle Crowe and the NREMT Research Team

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Appendix F. Survey Instrument for Specific Aim 3

Welcome Page

Thank you for agreeing to participate in this study! Results of this survey will help us to better understand the challenges faced by the EMS workforce.

The survey will take approximately 7 to 10 minutes. Your participation in this research project is entirely voluntary. The NREMT does not mandate/require participation in this project, and as such there are no penalties associated with not participating or discontinuing participation at any time. You may refuse to answer any question by selecting 'Next' to move to the next question. Additionally, you can quit the survey at any time. Further, there are no foreseeable risks in participation.

Please click 'Next' to continue.

1. To go back to a previous question, use the back arrow at the bottom of the page. Do NOT use your browser's back arrow.

216

1) How many years have you worked as an EMS professional? ( ) Less than one year ( ) 1-2 years ( ) 3-4 years ( ) 5-7 years ( ) 8-10 years ( ) 11-15 years ( ) 16-20 years ( ) 21 or more years

2) In addition to Mecklenburg EMS, for how many different organizations do you currently perform EMS work? (Do not count Mecklenburg EMS). ( ) 0 ( ) 1 ( ) 2 or more

3) In the past 30 days, have you provided patient care? ( ) Yes ( ) No

4) In general, how would you describe your health? ( ) Excellent ( ) Very good ( ) Good ( ) Fair ( ) Poor

217

Work-Related Burnout

5) Please read over each of the next statements and indicate how often the statement applied to you over the past 4 weeks.

Always Never or or Often Sometimes Seldom almost almost always never

I felt worn out at the ( ) ( ) ( ) ( ) ( ) end of my work day.

I was exhausted at the ( ) ( ) ( ) ( ) ( ) beginning of my shift at the thought of another day at work.

I felt that every ( ) ( ) ( ) ( ) ( ) working hour was tiring

I had enough energy ( ) ( ) ( ) ( ) ( ) for family and friends during leisure time.

My work was ( ) ( ) ( ) ( ) ( ) emotionally exhausting.

My work frustrated ( ) ( ) ( ) ( ) ( ) me.

I felt burned out ( ) ( ) ( ) ( ) ( ) because of my work.

218

Patient-Related Burnout

6) Please read over each of the next statements and indicate how often the statement applied to you over the past 4 weeks.

Always Never or or Often Sometimes Seldom almost almost always never

I found it hard to ( ) ( ) ( ) ( ) ( ) work with patients.

It drained my ( ) ( ) ( ) ( ) ( ) energy to work with patients.

I felt that I give ( ) ( ) ( ) ( ) ( ) more than I get back with patients.

I was tired of ( ) ( ) ( ) ( ) ( ) working with patients.

I wondered how ( ) ( ) ( ) ( ) ( ) long I will be able to continue working with patients.

7) How likely is it that you'll leave your current main EMS job within the next 12 months? ( ) Definitely will not leave ( ) Probably will not leave ( ) Probably will leave ( ) Definitely will leave

8) How likely is it that you'll leave EMS within the next 12 months? ( ) Definitely will not leave ( ) Probably will not leave ( ) Probably will leave ( ) Definitely will leave

219

9) In the past 12 months, have you been injured during a shift? ( ) Yes ( ) No

Logic: Hidden unless: Question "In the past 12 months, have you been injured during a shift?" #9 is one of the following answers ("Yes") 10) Did you report the injury to your employer? ( ) Yes ( ) No

11) In what year were you born? ______

12) What is your sex? ( ) Male ( ) Female

13) Which of the following best describes your current marital status? ( ) Married ( ) Divorced ( ) Widowed ( ) Separated ( ) Never been married ( ) A member of an unmarried couple

14) How many children less than 18 years of age live in your household? ( ) None ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( ) 5 ( ) More than 5

Thank You!

Thank you for participating in this important EMS research project!

220

Appendix G. Prenotification Slide for Specific Aim 3

221

Appendix H. E-mail Invitation to Participate in Electronic Questionnaire for

Specific Aim 3

From: Lester Oliva Subject: MEDIC EMS Research Study Good afternoon!

As you may have heard in announcements made earlier this month, MEDIC is supporting Remle Crowe, a Research Fellow at the National Registry of EMTs (NREMT) in conducting a survey regarding the well-being of the EMS workforce as part of her PhD dissertation work.

Your input is important. This survey will only take 5-7 minutes of your time. Your participation in this research project is entirely voluntary. MEDIC and the NREMT do not mandate or require participation in this project, and there are no penalties associated with not participating or discontinuing participation at any time. Further, there are no foreseeable risks in participation.

Your privacy is important to us, and your responses will be kept absolutely confidential. No one at MEDIC will have access to your individual answers and the NREMT will not release individual responses. Only data summarizing groups of participants will be reported. If you have any questions, or want to obtain more information about this very important project, please contact the NREMT Research Department at 614-888-4484 or via email at [email protected]. If you have concerns or questions about your rights as a participant, you can contact the Chair of AIR's Institutional Review Board at 1- 800-634-0797 or via email at [email protected]. Individuals who participate in the survey will be entered in a drawing to win 1 of 5 Amazon gift cards worth $100 each.

Click Here to Start the Survey

Once again thank you for your help!

Respectfully,

Lester Oliva, on behalf of Remle Crowe and The NREMT Research Team

222