In an individual’s academic career, there are several milestones that provide a profound feeling of accomplishment. Finishing one’s major post graduate research project is one of them. Over the past year, I have been afforded the opportunity to present my works-in-progress in Canadian Paramedicine, and it is with great appreciation I can now present some of the recommendations resulting from my research on paramedic resiliency to stress. To say stressful events are inherent in the role of a paramedic with the potential to cause injury here is to state the obvious. What is not so obvious is how the use of a reflective practice can improve resilience to occupational stress injury with the potential to facilitate growth where there is usually distress. My research, A new perspective on continuing mental health education: A case study on how reflective practice can improve resilience in paramedics, provides several recommendations that if adopted and practiced by paramedics, paramedic educational institutions, and paramedic services, can help mitigate the occupational stress injury that can unfold as a result of witnessing life and death on a daily basis. The study provided copious amounts of data in the form of paramedic descriptions of their lived experiences. This article will focus on some of the key recommendations resulting from the study.
It is important to understand the theoretical foundation I use to analyse the data that gives rise to the recommendations. The framework I use in the reflective analysis is a transformational learning framework. It is based on a constructivist philosophy where an individual’s lens through which they view the world is created by applying meaning to their experiences. Simply put, individuals experience the world and apply meanings to those experiences, building a unique set of opinions and core beliefs. Transformational learning occurs when we compare new experiences to past experiences, critically reflect on our prior assumptions and beliefs, and add to or revise meanings of those experiences, changing beliefs and behaviour. It is these opinions and core beliefs, and the ability to critically reflect on them, that are at the root of the conversation. In the following section, I will review the recommendations that were informed by the research, provide an inductive and reflective analysis for each one, and explain their significance.
New trainees must be informed early on in their training that they will experience critical stressors as a result of their chosen profession, and must be made aware of, and prepared for, a potential lifetime of transformation. “I was not aware that life was like this. I was naïve and socially awkward. I assumed [anxiety and distress] was normal, put on a brave face, and employed negative coping strategies. I was physically ill before each shift”. “When I graduated from college, I was not prepared that people actually die.” “You can never be fully prepared to see the things you see”. These are just some of the things the participants of the study said when we discussed their early career experiences. The common thread is that paramedicine introduced the new paramedics to a world they did not know existed, creating an internal conflict with the ‘normal’ they knew, and a ‘new normal’. This conflict, if unaddressed, can cause rumination; a revisiting of the experiences either consciously or unconsciously. This becomes what Mezirow1 calls a ‘disorienting dilemma’. It is perplexing. If nothing is done to cognitively address the differences between the new reality being presented and the realities the paramedics have built for themselves, the result can be distress. Yet to do something, i.e. critically reflect, there is potential for emotional upheaval. At the same time, how we deal with the disorienting dilemmas and reflect on what we do, or are expected to do as a paramedic, opportunities for transformation may be presented along with opportunities to build resilience
Critical reflection and critical thinking practice should become part of paramedic core training. We create our own realities. Our personal narratives and knowledge are socially and collaboratively constructed through dialogue, and it is this dialogue that can prompt critical reflection. Dialogue fostered by an event is where assumptions can be articulated, and perspectives tested against those of others and modified accordingly2, 3, 4. The events paramedics experience cause distress and create dilemmas resulting in a need to critically reflect to better understand the conflict, sometimes focusing inward attention, but requiring outward action to process the event and revise or create new meanings5. In the words of one of the participants, “Talking helps because it gets it from inside your head. It gets it from inside to the outside and it somehow loses its power when you speak it out loud. If you are harbouring any untruths, when you say something out loud and it is not true, it seems ridiculous, but inside, in your head, when you are trying to process things, sometimes it just stays stuck”. Paramedics experience dilemmas throughout their work and by engaging in the type of dialogue where meanings can be ascribed to the events they experience, they can begin making sense of it all. But, critical reflection is cognitively demanding. It challenges an individual’s core beliefs and assumptions thus being a potential cause of emotional upheaval1, 2, 4, 7 , and therefore there should be practice and guidance.
Paramedic clinical preceptor training should include methods on how to guide paramedic trainees through a reflexive process after experiencing critical stressors. This begins with the recognition of a disorienting dilemma for the new paramedic and the associated negative emotions, and then guiding the paramedic trainees through the discomfort using critical reflection and dialogue thus fostering transformation and growth. To accomplish the difficult task of mentoring new paramedics, relationships must be developed with the trainees that foster openness and reflective discourse, and the preceptor must be attuned to the trainee’s old reality and the new realities they are building for themselves5. A participant’s description of their experience highlights the importance,“I had a phenomenal preceptor, and I saw a lot of trauma during my preceptorship, and he was amazing at helping me deal with my emotions, coping with the situation, and just, you know, keeping an eye on me”. Through repeated practice of critical reflection and the transformational learning process during paramedic clinical preceptorships, paramedic trainees are well positioned for growth from their day-to-day critical stressors8. Additionally, experienced paramedics can learn and mentor peers in the same process of guiding others through the reflexive process, in a formal or informal method.
Critical self-reflection on critical stressors is a required skill and can be augmented by learning how to systematically self-reflect using patient documentation as a tool, filling in gaps i.e. events prior to the incident and patient outcomes. The participating paramedic’s told stories of numerous events that challenged their understanding of the world. These experiences created puzzles they needed to understand to reconcile them with how they previously saw the world. Piecing together the puzzles create narratives of the experiences, assisting with making sense of the experiences. Reflecting on narratives and understanding ‘the why’ contributes directly to the type of systematic reflection suggested by Merriam and Bierema9 that can facilitate the ability to make new meanings of experience and foster the capacity for transformational learning. A participant described the process of making sense and understanding why as a puzzle that needs to be solved. “I need to put all the pieces of the puzzle together at the end of it.” Others systemised the process to aid understanding: “I feel like putting it on your ACR [Ambulance Call Report] allows you to put things in chronological order… [a way] of getting all the facts to be part of that whole understanding thing.” Solving a puzzle using a systematic approach like documentation, incident reports, or even journaling, builds a narrative that can be critically reflected on to process the experience and create meaning. Through critical reflection on our experiences, where we analyse our assumptions and compare them with the perspectives of others, we can recreate our realities to match our new experiences.
Self-reflection should not be interrupted by others to initiate dialogue as individuals require time to process the event before talking about it, and for some, systematic reflection is sufficient to cognitively process the critical stressor. Readiness for change begins with self-examination of assumptions. Dialogue with others can lead to change, but there must first be an openness to critical reflection as it is cognitively demanding, uncomfortable for some, and a skill that takes time to develop2, 4, 6, 7. According to the participants, timing and sequence are important to be sure an openness exists. One participant said “I think that process needs to happen for them before they can tell me if they are fine or not. I find that maybe our paramedics are being contacted too quickly, I know for me, if somebody asked me if I am okay and I have not even done my ACR [Ambulance Call Report] yet or my incident report, of course, I am okay. I’m still running off adrenaline.” What is unknown and variable according to each individual is how long one should wait, a problem that could be addressed through education. Authenticity too is important. It is authentic individuals that are willing to engage in the type of discourse that can foster critical reflection5. Asking ‘how was your day’ or ‘are you ok?’ in the eyes of the paramedic is polite conversation and not an opening to the type of dialogue that fosters critical reflection.
This leads into the next recommendations. After paramedics have self-reflected either systematically and/or cognitively, if still required, defusing with peers, mentors, spouses, etc. through discourse and dialogue is recommended to foster further critical reflection and cultivate an openness to transformational learning. The participants only became open to critical reflection after a period of critical self-reflection, and then only if they felt the need. This highlights a limitation of the study. All participants of this study were able to self-identify the need to reach out for dialogue with others. A new question raised by the results of the research is, “are the paramedics who do experience occupational stress injury as a result of critical stressors not able to self-identify this need?” summing up the final recommendation: Defusing should only be offered if the individual reaches out, or if signs and symptoms of occupational stress injury are recognized by others (e.g. peers, supervisors, family etc.) thus reinforcing the important role of peers and peer support groups. As a cautionary note, stress management, coping strategies, and self-care should be employed to mitigate any lingering after effects of the critical stressor. Peer support or professional help should be sought out if still required.
This study was more than just about a reflective practice. It was about change or transformation. The results of the study imply that although the critical stressors created situations for occupational stress injury to occur, a possible contributor is the conflict between the realities paramedics have built for themselves and the realities they are faced with on a day-to-day basis. When one makes sense of one’s experience, one constructs the reality one lives in. Through critical thinking – critical self-reflection and critical reflection – paramedics can become open to transformation as opposed to experiencing distress. The information gleaned from this research reveals a link between transformational learning theory, the processes that promote post-traumatic growth, and how reflective practice can contribute to the mental well-being of paramedics. The outcome of this study provides a new perspective on continuing mental health education to improve resilience to occupational stress injury in paramedics through fostering transformative learning, using the lens of reflective practice.
(1) Mezirow J. Learning to think like an adult. In: Taylor E, Cranton P, editors. The handbook of transformational learning. Theory, research and practice. San Francisco, CA: Jossey-Bass 2012. p. 73-23.
(2) Brookfield S. Developing critical thinkers: Challenging adults to explore alternative ways of thinking and acting. San Francisco, CA: Jossey-Bass; 1987.
(3) Brookfield S. Critical theory and transformative learning. In E. Taylor & P. Cranton editors. The handbook of transformational learning. Theory, research and practice. San Francisco, CA: Jossey-Bass; 2012. p. 131-14.
(4) Cranton P. Understanding and promoting transformative learning: A guide to theory and practice 3rd ed [Kindle version]. Sterling, Virginia: Stylus Publishing; 2016.
(5) Ward, W., Boden, C., & Castleberry, A. Building resilience in healthcare professional trainees. In T. Carter, C. Boden, & K. Peno editors. Transformative learning in healthcare and helping professions education. Building resilient professional identities [Kindle version] (location 5676–8252). Charlotte, NC: Information Age Publishing Inc.; 2019.
(6) Pretorius L, Ford A. Reflection for learning: Teaching reflective practice at the beginning of university study. Int J Teach Learn High Educ. 2016;28(2):241-12.
(7) Taylor E, Cranton P.A theory in progress? Issues in transformative learning theory, Eur J Res Educ Learn Adult. 2013;4(1):35-12.
(8) Johansson, C., (2019). Therapists in the making. T. Carter, C. Boden, & K. Peno editors.Transformative learning in healthcare and helping professions education. Building resilient professional identities [Kindle version] (location 720–1150). Charlotte, NC: Information Age Publishing Inc.;2019.
(9) Merriam S, Bierema L. Adult learning: Linking theory and practice. San Francisco, CA: Jossey-Bass; 2014.