By Robin Young
We do for others, endure, and continue on…
Paramedics face multiple causes of work related stress in the field. In general, stress, although often times significant, is diminished by distance and time. The further you are away from the stressor and the longer the stressor is absent, the lessening of its impact. Commonly, low to moderate stress over a longer period of time resolves naturally. However, when faced with a personal threatening situation such as violence, the stress is of extreme intensity in a brief moment in time. For many, the psychological impact is significant and lasting. The threat of violence burns through any psychological defences and ignores the myth of the invincible uniform. It creates a lasting visceral response.
Violence, or the threat of violence, frequently happens in some form, ranging from an elderly patient panicking and pushing your hand away, to blatant physically assault. Currently, there is much focus on the physical act of violence towards paramedics, but physical violence need not occur for the paramedic to be psychologically impacted. The belief that personal harm is imminent can have tremendous psychological implications leading to immediate and/or long term stress related illness.
What is a Threat?
A threat is the words and actions of a person that compromises your sense of security and safety. It suggests escalation. It is a real or implied intention, means and opportunity to do you harm. It can be a physical action such as a person moving aggressively towards you, threatening words, the way a person is posturing, their distance to you, what they are holding in their hands or direct assaultive behavior. It may be the environment alone, such as a distressed patient located in a kitchen where there are many potential weapons available such as cutlery or glass.
A threat is also your perception and interpretation of another person’s attitude or action towards you. The level of threat you feel can be influenced by your mood, fatigue, past experience, training, general comfort level, emotions, or state of mind at the time. Your perception is also variable in that it can change from one moment to the next based on changing information, lack of information, or others’ experience in similar situations. Threat assessment may be complicated by your partners differing interpretation or tolerance towards the situation based on their past experiences, training, abilities, and/or states of mind. You may sense danger but your partner does not, or she may but you do not. Overall, the fact that you feel threatened in some way means that your survival instincts have kicked in and demand action to keep safe.
Threat assessment refers to using observation and analytical skills to identify the reason for feeling at risk, the level of danger, and the timing of danger. The objective is to make as early and as accurate an assessment as possible; to gain as much information about another person’s intention towards you. To be able to have an effective threat assessment, there needs to be space and time: the more space and time to observe, the more accurate the assessment.
Developing accurate observation skills is vital. They give you familiarity with possible intentions. Being familiar with the potential meaning of physical behaviours such as facial expression, hand positioning, body positioning, physical distancing, shape of clothing (hidden weapons), among others, can decrease risk towards you and your partner by giving you time to act. Threat assessment begins as early as possible. If you can determine the level and timing of danger you are in you can initiate the appropriate response, be it verbal intervention to defuse the situation, defending yourself, or rapidly escaping the threat. The less time available to assess the evolving situation can lead to inaccurate conclusions and an over or under reaction to a situation. More time can lead to more situational control.
Many paramedic educational programs and services have a component of their training dedicated to assessing personal safety but much of the skills are learned on the job, from more experienced partners and your own experiences over time. Intuition, “gut feelings”, comes naturally to some or is strengthened over time.
The difficulty with threat assessment in paramedicine is that a situation with a patient can change in an instant. Paramedicine is a double edged sword, where you need to be contact-close to the patient to provide effective patient care but, by being so close, you are extremely vulnerable if a threat materializes. A totally compliant patient becomes an extremely combative patient and you have little or no time to protect yourself or escape. From a therapeutic mindset, you are forced into a survival mindset with few options.
Situational awareness refers to the knowledge of what is happening around you. It is not static. Continual awareness of your evolving situation is a major component of threat assessment. By being in an constant observational mindset, you are more likely to pick up presented danger signals. Noticing situational changes in patient behaviour, verbal communication, and physical distance can give you time to shift your strategy towards either regaining control the situation or withdrawing to safety. Situational awareness can be compromised by work fatigue, relaxed mindset, distraction, complacency, altered emotional state or over-confidence. At 0300 on your third night shift, it can be difficult to maintain a continuous high state of awareness. Also, once focused on patient care, you are less likely to register adverse changes in your patient’s behaviour. Your partner can focus on situational awareness as you tend to patient care. She can better detect escalating behaviour and either warn you or intervene to de-escalate or assist with escaping the threat.
Tactical thinking is a concept that stresses simplicity and efficiency in responding to threats by accurately identifying and accepting the situation and level of personal threat (low, medium, high), the type of threat (verbal, physical, weapons, environment). It involves knowing your options and deciding on the appropriate one, and putting that option into action, such as: recognizing and avoiding the threatening situation, verbally diffusing it, withdrawing, defending yourself, or escaping. It is important to communicate with your partner to counter any disconnection with the threat to ensure you are both assessing the situation the same way. This can be done covertly with a pre-arranged safety phrase or overtly (moving you and your partner to an exit). Learn, train, gain experience, listen to others and use what works to stay safe.
Typically, there are three ineffectual responses to a threat as your sympathetic nervous system triggers survivor mode: Indecision, Over Reaction, or Under Reaction. When faced with high intensity information, excessive, conflicting, or uncertain information, your nervous system cannot process effectively or decide how to respond. There is behavioural hesitation in attempts to clarify the information, prioritize it, compare it to existing experiential/social templates, or otherwise manage it. If the information cannot be processed appropriately, the processing shuts down and there is prolonged indecision (“freezing”) and no action is taken towards the information being presented. It may be a conscious disbelief (this is not happening) or contradictory socialization (people are not violent), or multiple sources (several people) that stops appropriate “fight or flight” instinctive survival actions. Perhaps previous experiences with violence have affected any ability to respond. If the information of the threat is interpreted to be high, but in actuality is not, you may over react, perhaps unnecessarily engaging a threat that does not exist. You may under react when interpreting the threat as less than it actually is and not respond effectively, perhaps by not registering pre-violent behaviour cues or staying too long in an escalating environment.
You have varying levels of skills, training, psychologic and physiologic reserves, natural resilience and life experience. You bring into the paramedic profession unique sets of skills for a multitude of situations. There may not have been any physical harm. Non-physical threats can still lead to mental/emotional unease or injury such as short term or long term fear, depression, anxiety, work avoidance, substance abuse, or other concerns. Once away from the threat, access the appropriate assistance as needed: police, medical, personal, legal, and/or paramedic service resources. Report, document, and seek legal recourse, if necessary. Know your rights, service policies and available resources.
Your profession is one of compassionate public service. There is an expectation of wellbeing while at work. Threats to your safety, be they suggestive or tangible, are never acceptable.
Be safe out there.
ABOUT THE AUTHOR
Robin Young recently retired after teaching 30 years as a paramedic professor in the Ontario Community College system. He has an M.A. in Adult Education from Central Michigan University and an Honours B.Sc. in Health Studies from the University of Waterloo. Robin is an A-EMCA and formerly worked with Toronto Paramedic Services.
References and readings on this topic:
- De Becker, G. (1998). The gift of fear and other survival signals that protect us from violence. New York: Dell.
- Miller, R. K. (2011). Facing violence: preparing for the unexpected: ethically, emotionally, physically (…and without going to prison). Wolfeboro, NH: YMAA Publication Center.
- Remsberg, C. (1986). The tactical edge: surviving high-risk patrol. Northbrook, IL: Calibre Press.
- Wilder, S. and Sorensen, C. (2001). Essentials of Aggression Management in Health Care. New Jersey: Prentice-Hall, Inc.
- Young, W. R. (2013) Paramedic self-defence: a guide to personal protection for paramedics and other health care professionals. Toronto: Harris Media Group.