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Journal Watch: Stress and Safety

Reviewed This Month

What Influences Safety in Paramedicine? Understanding the Impact of Stress and Fatigue on Safety Outcomes

Authors: Donnelly EA, Bradford P, Davis M, et al.   

Published in: JACEP Open, 2020; 1: 460–73. 

Most of the time in Journal Watch we review studies focused on either EMS patients or EMS providers. This month we review an interesting study that examines the safety of both.

The authors of this study note EMS is an inherently stressful profession and that some chronic stressors may have an impact on safety. They defined chronic stress as stresses that are relatively stable and consistent over time. They identified operational, organizational, and critical incident stress as potentially influencing safety.

Operational stress is the stress of working in the EMS field regardless of service. Organizational stress is the stress associated with working for a specific EMS service. Critical incident stress is the stress associated with patient care.

The authors also evaluated post-traumatic stress and fatigue. Both have been shown in previous research to be associated with negative impacts on patient and provider health and/or safety. 


The authors of this study sought to “examine the relative influence of chronic operational stress, chronic organizational stress, critical incident stress, post-traumatic stress, and fatigue on safety outcomes.” To evaluate safety outcomes, this study used the EMS Safety Inventory, which assesses injuries and exposure to pathogens and safety-compromising behaviors (such as speeding for nonemergency transports), as well as medical errors and adverse events. 

This study utilized an online survey to address its study objective. To recruit paramedics to participate, the authors first sent e-mails to a list of chiefs of paramedic services in Ontario, Canada. Chiefs were asked to share e-mail addresses for their staff.

All paramedics in services that agreed to participate first received an e-mail from leadership in their service indicating their support for the study, that participation was voluntary and confidential, and that the medics would be permitted to respond to the survey while at work. A subsequent e-mail sent from the study team invited the paramedics to participate in the study. 

The authors wisely chose to use survey questions that had been validated in previous studies. To evaluate work-related stresses, they utilized the Emergency Medical Services Chronic Stress Questionnaire. This questionnaire assesses operational and organizational stress. 

Critical incident stress was assessed using the EMS Critical Incident Stress Inventory. This inventory evaluates patient care-related stresses. To evaluate post-traumatic stress, the authors used the PTSD Checklist-Military, a 17-question scale used in previous studies of paramedics. Finally, the Chalder fatigue scale was used to assess the sense of tiredness an individual experiences.

As you may have deduced, this was a long survey, at 167 questions. It was quite an undertaking for the investigators to follow up with respondents and help get the response rate as high as possible. They even offered an incentive: Those who responded were entered into a drawing to receive Android tablets. 


At the end of the study period, 10 paramedic services agreed to participate. Of the 1,767 paramedics in these services, 825 (47%) responded to the survey. The authors only utilized responses for those who completed at least 80% of the survey questions.

Therefore, 717 (41%) of respondents were included in the analysis. Most (66%) were male, indicated their race was white (93%), and had an average age of 38 years. The average number of years in EMS was 14. Almost all (99%) reported working 12-hour shifts, and most respondents worked between 41–60 hours per week.

With respect to the safety outcomes of interest, 80% of respondents reported an injury or exposure, 95% reported at least one safety-compromising behavior, and 76% of respondents reported an adverse event or medical error. A clear majority (55%) reported they were fatigued after work, and 15% reported post-traumatic stress symptomatology.

All stress factors, including operational, organizational, critical-incident, post-traumatic, and fatigue, were significantly associated with the safety outcomes assessed (p<0.01). Paramedic age and years of experience were also significantly associated with safety-compromising behaviors and medical errors or adverse events (p<0.01).

Specifically, younger paramedics and those with fewer years in EMS reported higher levels of both outcomes. Increased hours worked weekly (p<0.01) and working more than one job (p<0.05) were also significantly associated with unwanted safety outcomes. 

The significant relationships between stress factors, fatigue, and unwanted safety outcomes remained significant after multivariable modeling. In other words, after controlling for other factors and demographics, the relationship was still statistically significant. 

The authors also sent a follow-up survey to those who decided not to respond to the entire survey. This is called a nonresponder survey, and it is undertaken to determine whether those who responded are different in one way or another from those who did not respond.

In this case, the authors were not seeking to determine whether stress levels or safety outcomes were different but rather if there was a demographic difference between those who chose to respond and those who did not.

There were 69 responses to this follow-up survey from nine paramedic services. There was no statistically significant difference noted in age, years of experience, gender, marital status, level of certification, hours worked weekly, ethnicity, or income (p>0.05). Those who did not respond to the original survey did hold fewer paramedic jobs (p<0.01). 


Since many of us are working on maintaining our New Year's resolutions, a few suggestions came out of this study to help keep our patients and ourselves safe. These included implementing a fatigue-management strategy based on published guidelines and mitigating workplace stresses by providing confidential access to mental health services.

The authors wisely note it is not possible to remove all stress factors in our profession but “work can be done.” This was a very interesting study that adds to the existing literature on stress, fatigue, and negative safety outcomes in EMS.   

Antonio R. Fernandez, PhD, NRP, FAHA, is a research scientist at ESO and an assistant professor in the department of emergency medicine at the University of North Carolina–Chapel Hill. He is on the board of advisors of the Prehospital Care Research Forum at UCLA.

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