A wide range of factors have been identified as working positively or negatively to influence the health and wellness of paramedics, especially in terms of their mental health (1, 2). While there has been needed conversation about stress and posttraumatic stress, there has been less discussion about the impact of an individual’s sense of identity on their mental well-being. When we say “identity,” we mean how someone thinks about themselves in their role (e.g., working as a paramedic). This sense of identity can have a significant impact on how paramedics navigate challenges to their well-being and can influence their overall resilience.
How do we develop our identities? Identity is created through a range of processes. The concept of identity can be viewed in terms of the culture of the profession (that is behaviours and views held commonly by paramedics as an occupational group), organizational identity (that is identity created by having a shared employer or membership of an organization) and individual identity (the identity which people bring to the profession based on their own culture, upbringing, etc.). Formation of identity in a health profession is based on a range of factors. At the core is the individual’s identity as a person. This is formed through genetics (that is, gender and ethnicity, for example), upbringing, religious or philosophical views, life experience and a range of other factors. Individual identity is the basis on which a professional identity is formed, and as such those underlying characteristics make the individual’s professional identity unique, even if they operate in the same environment with the same training as others (3). Professional identity is further formed through socialization and establishing a clear role. Once this identity if formed, then it influences how the individual sees the world. A useful way of understanding this process is found in Social Identity Theory, where individuals gain a sense of identity through belonging to a group or having a common role (such as being a paramedic). This identity is created by participating in activities such as student clinical placement or social ritual (beginning of shift coffee) which provide a sense of belonging or acceptance (4). Role is an important part of identity as it both creates a lens through which the paramedic sees the world and creates a framework in in which they act (5).
The concept of role is often a challenging one for paramedics. Over time, the traditional role of paramedics has changed. In many cases, the role paramedics signed up for at the beginning of their career is not identical to the one they have now; the identity of paramedics has constantly been in flux with changes in scope, education and role. In a sense, paramedics did not join a profession with a stable sense of identity, the profession has formed and changed around them (6). Examples of these changes might include increasing levels of autonomy in clinical decision-making, access to increasingly advanced interventions, the introduction of self-regulation through the development of Colleges of Paramedicine, or the evolution of Community Paramedicine.
The sense of confusion or frustration in their role as a paramedic can lead to role dissonance. Role dissonance creates tension and anxiety between what the public expects or needs and paramedic’s view of how they should play a part in healthcare. Role dissonance essentially refers to a disconnection between a paramedic’s view of what their role should be and what is actually occurring. Role dissonance occurs for many reasons. Newly qualified paramedics may grapple with the disconnect between the high-acuity nature of their training compared with the increasingly large low acuity workload (7). For example, new paramedics may be expecting to respond primarily to VSA or traumatic injury calls, only to find the majority of their calls are exacerbations of chronic illness or other non-emergent concerns. Dissonance for longer serving paramedics might include struggles with the changes in workload compared to when they entered the profession – for example, paramedic responses to patients with mental health issues or who were socially isolated were less common twenty years ago but are not a regular feature of paramedic work. (6). Role dissonance can occur as a natural part of paramedic workflow. Cognitively and emotionally, paramedics are required to regularly switch modes from rescuer to carer for example when a fast paced high acuity cases like a major trauma is immediately followed by a very complex less time-critical case such as a patient with a chronic disease exacerbation who is socially isolated. Both cases require different skill sets and different mental focuses but are equally important parts of the paramedic role. Switching between these modes in quick succession can be challenging (7). Regardless of the nature of the dissonance, feeling like one is doing a different job to what they believe is their role or feeling like they have multiple disparate roles creates a conflict of identity and purpose which can create frustration and anxiety which has a negative effect on coping and resilience.
IDENTITY, RESILIENCE, AND COPING
How does role identity influence our professional lives? One way in which identity may influence paramedics is in the relationship between identity and resilience. Resilience is essentially the capacity to recover or “bounce back” from a challenging or threatening situation. Specifically, an established professional identity has been identified as a factor that supports well-being and resilience (8, 9)
Perception of role and role identity has given rise to coping mechanisms to support the view of what paramedic identity should be. This includes storytelling, cultural ritual and reinforcement of perceived role (7). Some of these coping mechanisms are useful, however some can be maladaptive and further reinforce the role dissonance through stigmatising those who don’t fit into the perception of role (for example, patient shaming)(10). However, positive storytelling with supportive colleagues can have a positive effect on resilience (11) as can black humour, which is a common part of paramedic culture and is recognized as having bona fide effects on coping (12).
HOW DO WE MANAGE ROLE DISSONANCE?
Coping with role dissonance can be challenging. Unlike many of the external factors which influence paramedic wellness, role dissonance occurs internally creating an existential anxiety which underpins a paramedic’s resilience and sense of identity. There are a number of strategies that can potentially assist in mitigating the impact of role dissonance.
Having a strong identity outside of paramedicine
Many paramedics place their paramedic role at the core of their overall identity. It is important to have this balanced with a strong personal identity that is not contingent on the paramedic role. This includes having strong social relationships, hobbies, etc., which create alternative senses of purpose and identity. Having an good work-life balance has been shown to be a positive influence on resilience (8).
Reframe Professional Identity and Professional Satisfaction
Having clarity in professional identity has also been shown to have a positive influence on resilience (8). While the rapid nature of change in paramedicine is challenging to navigate, the trend is toward a profession that is more caring and patient-centred. Reframing practice in this way which creates intrinsic systems of satisfaction for a range of cases and patient types can reduce the dissonance between the more tangible satisfaction for a positive outcome in a high acuity case (for example, getting ROSC) and the less tangible outcomes of less time-critical and high acuity cases (for example, improving a patient’s health literacy around self-care for their diabetes).
Build an Identity Based on Values
Roles are often defined by the activities people undertake. However, there is significant for supporting professional identity with values. Values refers to the belief system and principles which underpin our practice and how we see the world from an ethical point of view. Values have been shown to have a positive effect on resilience (8). By incorporating values into professional identity, there is a basis of identity which is not dependent on the activities the paramedic is undertaking which have traditionally been linked to the “quality” of the case (i.e. giving drugs, inserting an airway, etc.) A values-based practice ensures that each patient, even those requiring no clinical interventions are treated in a way consistent with professional values, like treating a socially isolated patient with compassion and empathy. The rise of values-based practice (VBP) provides a framework for paramedics to make consultative decisions with patient stakeholders that are based on both evidence and values (13).
There is tremendous power in how we think about our work in paramedicine. How we think about our work and the degree to which we can manage the complexities of what it is to be a paramedic can influence our mental health. While not as widely studied as other influences on paramedic mental health, it is important that paramedics understand that role dissonance may a negative impact on well-being (5). Beyond a simple awareness of the impact of role dissonance, it is important that paramedics learn and employ strategies to mitigate the effects of dissonance on well-being.
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