Running head: COMPASSION FATIGUE IN EMERGENCY MEDICAL COMPASSION FATIGUE IN EMERGENCY MEDICAL SERVICES (EMS): THE INFLUENCE OF SELF-CARE ON COMPASSION FATIGUE AMONG EMS PROFESSIONALS IN NORTHWESTERN PENNSYLVANIA By Kelly Martin, BSEd, BSN, MSN MSN, Clarion and Edinboro Universities, 2015 BSN, Edinboro University, 2009 BSEd, Edinboro University, 2006 A DNP Research Project Submitted to Clarion and Edinboro Universities In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree December, 2017 COMPASSION FATIGUE IN EMERGENCY MEDICAL Compassion fatigue in emergency medical services (EMS): The influence of self-care on compassion fatigue among EMS professionals in Northwestern Pennsylvania Committee Signature Page Student’s name Committee Chairperson Committee Member Committee Member ii COMPASSION FATIGUE IN EMERGENCY MEDICAL Dedication I dedicate this study to the men and women working in Emergency Medical Services who devote their lives to serving others in need during times of tragedy and crisis. iii COMPASSION FATIGUE IN EMERGENCY MEDICAL Acknowledgements I would like to acknowledge my committee, Dr. Terri Astorino, Dr. Viki Hedderick, and Julie Schaefer, PA-C as well as my statistical consultant, Dr. Amy McClune, for the guidance and expertise they provided throughout the successful completion of this study. iv COMPASSION FATIGUE IN EMERGENCY MEDICAL COMPASSION FATIGUE IN EMERGENCY MEDICAL SERVICES (EMS): THE INFLUENCE OF SELF-CARE ON COMPASSION FATIGUE AMONG EMS PROFESSIONALS IN NORTHWESTERN PENNSYLVANIA Kelly Martin, MSN, BSN, BSEd, CRNP, PHRN Abstract Compassion fatigue, also known as secondary traumatic stress disorder, results from repeated exposure to the suffering of others, eventually exhausting his or her ability to show compassion. Self-care has been suggested as a potential preventative or treatment strategy in compassion fatigue however there has been limited documentation to validate this relationship. This study utilized a non-experimental, descriptive correlational design in order to determine if EMS professionals in Northwestern Pennsylvania, who practice self-care, experience less compassion fatigue than those who do not. A survey which was comprised of The Professional Quality of Life (ProQOL) scale, a validated tool for assessing compassion fatigue by evaluating secondary traumatic stress, burnout, and compassion satisfaction, as well as the Health Promotion Lifestyle Profile (HPLP) II, a tool to evaluate health promotion/self-care, was completed by 164 EMS professionals in Northwestern Pennsylvania. Spearman’s rank correlation coefficient was utilized to determine the relationship between self-care and compassion fatigue. The results demonstrated a negative correlation between self-care and burnout (p<.000), a negative correlation between self-care and secondary traumatic stress (p<.000), and a positive correlation between self-care and compassion satisfaction (p<.000), suggesting lower levels of compassion fatigue in those who practice self-care. These findings suggest that the implementation of selfcare may result in decreased compassion fatigue, improving the EMS professional’s quality of life as well as patient outcomes. v COMPASSION FATIGUE IN EMERGENCY MEDICAL Table of Contents Introduction ..................................................................................................................................... 1 Background of the Problem ......................................................................................................... 2 Statement of the Problem ............................................................................................................ 6 Research Question ....................................................................................................................... 6 Definition of Terms ..................................................................................................................... 7 Need for the Study ....................................................................................................................... 8 Significance of the Problem ........................................................................................................ 8 Assumptions ................................................................................................................................ 9 Summary of the Problem ............................................................................................................. 9 Review of Related Literature ........................................................................................................ 10 Compassion Fatigue in EMS and fire department personnel .................................................... 10 Compassion Fatigue in Nurses and Physicians ......................................................................... 13 Strategies in the Prevention and Management of Compassion Fatigue .................................... 15 Gap in the Literature .................................................................................................................. 17 Theoretical Framework.............................................................................................................. 18 Summary of the Review of Related Literature .......................................................................... 20 Methodology ................................................................................................................................. 20 Research Design ........................................................................................................................ 21 Setting ........................................................................................................................................ 21 Sample ....................................................................................................................................... 21 Ethical Considerations ............................................................................................................... 21 COMPASSION FATIGUE IN EMERGENCY MEDICAL Instrumentation .......................................................................................................................... 22 Data Collection .......................................................................................................................... 24 Data Analysis ............................................................................................................................. 25 Summary of Methodology ......................................................................................................... 25 Results and Discussion ................................................................................................................. 25 Description of the Sample ......................................................................................................... 26 Summary.................................................................................................................................... 31 Summary, Conclusions, and Recommendations ........................................................................... 32 Interpretation of the Findings .................................................................................................... 32 Theoretical Framework.............................................................................................................. 34 Limitations ................................................................................................................................. 35 Recommendations for Future Research ..................................................................................... 36 Implications for EMS Professionals .......................................................................................... 37 Conclusion ................................................................................................................................. 39 References ..................................................................................................................................... 41 Appendices .................................................................................................................................... 45 Appendix A: Permission Letter from EMMCO West ............................................................... 45 Appendix B: Permission to use the ProQOL, version 5 ............................................................ 46 Appendix C: Permission to Use the HPLP II ............................................................................ 47 Appendix D: Edinboro University IRB Approval Letter .......................................................... 49 Appendix E: Collaborative Institutional Training Initiative (CITI) Certificates ....................... 51 Appendix F: Consent to Participate in Research Study/Survey ................................................ 54 vii COMPASSION FATIGUE IN EMERGENCY MEDICAL Appendix G: Permission to Utilize Survey Monkey for Research Study ................................. 56 Appendix H: Survey (ProQOL 5, HPLP2) ................................................................................ 57 viii COMPASSION FATIGUE IN EMERGENCY MEDICAL List of Tables Table Page 1: Component of Compassion Fatigue vs Self-care...........................................................28 2: Component of Compassion Fatigue vs Categories of Self-care ....................................30 ix COMPASSION FATIGUE IN EMERGENCY MEDICAL List of Figures Figure Page 1: Relationship between compassion satisfaction and compassion fatigue. ........................4 x COMPASSION FATIGUE IN EMERGENCY MEDICAL COMPASSION FATIGUE IN EMERGENCY MEDICAL Compassion fatigue in emergency medical services (EMS): The influence of self-care on compassion fatigue among EMS professionals in Northwestern Pennsylvania Chapter 1 Introduction Compassion fatigue, also known as secondary traumatic stress disorder, continues to be a growing concern across many health care disciplines. Compassion fatigue results from repeated exposure to the suffering of others, causing the health care provider to vicariously experience a trauma similar to that of the patient, eventually exhausting his or her ability to show compassion for others (Bush, 2009.) Compassion fatigue manifests as various physical, emotional, spiritual and social signs and symptoms which have deleterious effects on the health care provider both personally and professionally (Henson, 2017.) As a result, the attitude of the health care provider, ability to effectively fulfill his or her role, and patient outcomes are all negatively impacted (Rosenstein, 2013.) If proper interventions are not carried out to combat compassion fatigue, these symptoms become progressively worse (Bush, 2009.) According to Boyle, 2011, without early identification and treatment, the health care provider may experience a permanent inability to provide care and demonstrate compassion for others. Studies in both the nursing and physician population indicate that the development of compassion fatigue is a contributing factor to high turnover of health care professionals (Rosenstein, 2013.) According to Crim, 2017, interventions, including implementation of self-care, may be a potential strategy in the prevention and remediation of compassion fatigue. Self-care encompasses behaviors and activities that counteract the effects of physical and emotional stress (Meinecke, 2010.) COMPASSION FATIGUE IN EMERGENCY MEDICAL Examples of self-care activities include achieving adequate sleep, good nutrition, regular exercise, yoga, meditation, relaxation techniques, engaging in hobbies and participating in counseling (Meinecke, 2010.) While the concept of compassion fatigue is becoming more familiar in the health care arena, there remains a gap in the literature. Although there are numerous studies evaluating the presence of compassion fatigue in the nursing and physician population, there is a lack of studies regarding compassion fatigue in emergency medical services (EMS) professionals. The purpose of this correlational study is to identify a relationship between self-care practices and compassion fatigue among EMS professionals in Northwestern Pennsylvania. EMS professionals were asked to complete the Professional Quality of Life (ProQOL) survey as well as the Health Promotion Lifestyle Profile II (HPLP II) in order to evaluate the relationship between compassion fatigue and self-care practices. Background of the Problem Compassion fatigue develops due to ongoing exposure to the pain and suffering of others and observation of traumatic circumstances on a regular basis (Wentzel & Brysiewicz, 2014.) A health care provider that experiences compassion fatigue may develop negative physical, spiritual and psychological effects that affect his or her personal and professional life (Boyle, 2011.) Physical effects of compassion fatigue include immunosuppression, exhaustion, myalgias, dizziness, gastrointestinal symptoms, insomnia, excessive sleep and cardiac rhythm disturbances (Bruner & Rhodes, n.d.; Lombardo & Eyre, 2011.) Compassion fatigue can manifest as psychological symptoms which include anxiety, fear, guilt, anger, irritability, sadness and depression, substance abuse, memory impairment, inability to focus and poor decision making (Bruner & Rhodes, n.d.; Lombardo & Eyre, 2011.) Spiritual effects, such as questioning 2 COMPASSION FATIGUE IN EMERGENCY MEDICAL the meaning of life and prior spiritual beliefs, feeling as though one is unable to make a positive difference in the world, as well as believing the world is malevolent are all associated with the presence of compassion fatigue (Bruner & Rhodes, n.d.) According to Aycock & Boyle, 2009, diabetes mellitus, hypertension, cardiovascular disease and obesity may also be consequences of compassion fatigue. A study conducted by El-bar et al., 2013, evaluated 3 concepts that may influence the development of compassion fatigue: compassion satisfaction, secondary traumatic stress and burnout. Compassion satisfaction is the result of the positive aspects of serving as a health care provider (Stamm, 2010.) Compassion satisfaction encompasses three components of serving as a caregiver: (1) the sense of fulfilment one experiences from carrying out his or her role; (2) the caregivers perceived personal job performance as it relates to both ability and the level of control he or she has over his or her exposure to secondary traumatic stress; (3) the amount of camaraderie experienced by the caregiver and his or her colleagues (Sodeke-Gregson, Holttum, & Billings, 2013.) Secondary traumatic stress, which is the trauma experienced second-hand by a person caring for an individual undergoing a traumatic event, may cause the caregiver to vicariously experience a similar trauma leading to an acute reaction that is comparable to those suffering from post-traumatic stress disorder (Sodeke-Gregson et al., 2013.) Burnout is the final element that relates to the development of compassion fatigue. The concept of burnout is specific to the work environment and can be experienced in all professions. Factors which contribute to the development of burnout include long work hours, understaffing, and serving within a demanding role. Burnout differs from compassion satisfaction and secondary traumatic stress in that the two latter concepts occur only among caregivers (Sodeke-Gregson et al., 2013.) 3 COMPASSION FATIGUE IN EMERGENCY MEDICAL As demonstrated in figure 1, it is suggested that secondary traumatic stress, combined with existing burnout, contributes to the development of compassion fatigue. In health care, particularly in EMS, personnel are required to work long hours ranging from twelve to twentyfour-hour shifts, are often understaffed due to inability to recruit and retain qualified employees and are routinely exposed to secondary traumatic stress, placing them at high risk for the development of compassion fatigue. Figure 1: Relationship between compassion satisfaction and compassion fatigue. Adapted from the Professional Quality of Life Elements Theory and Measurement website. (2017). proqol.org The relationship between compassion satisfaction and the development of compassion fatigue is ambiguous. According to El-Bar et al., 2013, a caregiver suffering from compassion fatigue may have an inability to experience compassion satisfaction. This may be due to an 4 COMPASSION FATIGUE IN EMERGENCY MEDICAL inability to harbor positive feelings about a role that is negatively impacting the caregiver personally and professionally. Another explanation for this phenomenon may be the rate at which compassion fatigue develops versus compassion satisfaction. Compassion fatigue is thought to develop acutely and therefore may not be counteracted by compassion satisfaction, which develops via a slower process (Thompson, 2013.) Marion Conti-O’Hare’s theory of the nurse as wounded healer serves as the theoretical framework for this study. This model suggests that nurses as well as other health care professionals, through experiencing and managing trauma within their own lives, may be able to convert from walking wounded to wounded healers (Nurse as Wounded Healer website, 2017.) The theory assumes that all humans experience trauma and for caregivers, this trauma may be of both personal and professional origin. It is suggested that trauma will not resolve without intervention and the way in which the caregiver copes with trauma dramatically affects patient care. People have the ability to change their self-concepts, mindset and behavior which may lead to an ability to demonstrate empathy, develop a rapport and provide unconditional support to others, all of which promote the transformation from walking wounded to wounded healer (Conti-O’Hare, 2002.) If the caregiver is able to heal from his or her personal or professional trauma, he or she may use that experience in a therapeutic manner to help others (Nurse as Wounded Healer website, 2017.) This study relates to this framework by suggesting that with an intervention such as selfcare, EMS professionals may be able to recover from professional trauma, like secondary traumatic stress disorder, also known as compassion fatigue. It also implies that the EMS 5 COMPASSION FATIGUE IN EMERGENCY MEDICAL professional may be able to use the experience of overcoming compassion fatigue to strengthen his or her ability to show empathy and provide therapeutic benefit to others. Statement of the Problem EMS professionals are required to care for others in times of tragedy and crisis. Due to the nature of the profession, they repeatedly witness traumatic events, pain, and suffering of others. In addition, they are at high risk for burnout due to long work hours, increasingly high demands, understaffing, low wages, inadequate rest and meal breaks, as well as insufficient protection against violence (Jacobs, Heller, Waheed, & Appel, 2017.) These circumstances place EMS professionals at great risk for the development of compassion fatigue. While there are numerous studies regarding compassion fatigue in other professionals, there are few that address compassion fatigue as it relates to EMS professionals. Self-care has been suggested throughout the literature as a potential treatment or preventative measure for compassion fatigue, however there is limited data documenting a correlation between compassion fatigue and the practice of self-care strategies. Identifying potential preventative or remedial strategies to combat compassion fatigue in a high-risk group of health care professionals, such as those working in EMS, would allow for the development of effective programs to improve the lives of EMS professionals, patient care, as well as contribute to employee retention in a field that is currently struggling to maintain adequate staffing. Research Question The goal of this study was to answer the following question: 1. Do EMS professionals in Northwestern Pennsylvania, who practice self-care, experience less compassion fatigue than those who do not? 6 COMPASSION FATIGUE IN EMERGENCY MEDICAL Definition of Terms The following list includes conceptual definitions of terms used within this study: 1. Emergency Medical Services (EMS) professionals is defined as unique health care professionals in that they provide medical care and transportation in an out-ofhospital setting with medical oversight. EMS professionals are not independent practitioners. While the practice is not independent, it is relatively unsupervised and often has little backup. Therefore, EMS professionals must be able to exercise considerable judgment, problem-solving, and decision-making skills.” (National Highway Traffic Safety Administration [NHTSA], 2007, p. 18.) 2. Compassion fatigue is defined as “the emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events. It differs from burn-out, but can co-exist. Compassion Fatigue can occur due to exposure on one case or can be due to a ‘cumulative’ level of trauma.” (The American Institute of Stress website, 2017, expression 1.) Compassion fatigue may manifest as physical, spiritual and psychological effects such as sleep disturbance, exhaustion, anxiety, irritability, depression, illness and a state of questioning one’s prior spiritual beliefs (Bruner & Rhodes, n.d.; Lombdardo & Eyre, 2011.) 3. Health care provider is defined as a “person who provides any form of health care” (“Health care,” 2002). 4. Compassion satisfaction is defined as the pleasure experienced from helping others in need, having positive feelings about coworkers, and making a contribution to society through one’s work in aiding others (Stamm, 2010). 7 COMPASSION FATIGUE IN EMERGENCY MEDICAL 5. Burnout is defined as a state of physical, mental, and emotional exhaustion brought on by repeated exposure to stressful conditions. Burnout differs from compassion fatigue in that it affects people working within any field that experience low work satisfaction and are subject to exceedingly high work-related demands (El-bar, Levy, Wald, & Biderman, 2013.) 6. Self-care is defined as behaviors and activities that counteract the effects of physical and emotional stress. Examples include achieving adequate sleep, good nutrition, regular exercise, yoga, meditation, relaxation techniques, engaging in hobbies and participating in counseling (Meinecke, 2010.) Need for the Study Compassion fatigue, a growing concern among health care providers, has been associated with the dissociation from oneself and substandard patient care (El-bar et al., 2013.) Although studies conducted among other health care disciplines suggest that self-care strategies may prevent or treat compassion fatigue, there have been no studies identified which evaluate the correlation between self-care and the presence of compassion fatigue among EMS professionals. Identifying a potentially effective strategy, such as the implementation of self-care activities, within a high-risk group of health care providers, may facilitate the development of effective prevention and intervention, resulting in improved patient care, provider satisfaction, and retention of personnel. Significance of the Problem According to Coetzee and Klopper, 2010, “compassion fatigue is the final result of a progressive and cumulative process that is caused by prolonged, continuous, and intense contact 8 COMPASSION FATIGUE IN EMERGENCY MEDICAL with patients, the use of self, and exposure to stress, which manifests with marked physical, social, emotional, spiritual and intellectual changes that increase in intensity” (p.237.) Given the deleterious effects of unidentified or mismanaged compassion fatigue, it is necessary to identify potential strategies to promote awareness, prevention and treatment. Without appropriate and timely intervention, the manifestations of compassion fatigue, including physical, professional, and emotional signs and symptoms, may be irreversible (Boyle, 2011). Assumptions The study assumes the following: 1. EMS professionals surveyed have experience providing patient care. 2. EMS professionals surveyed have answered questions truthfully 3. EMS professionals surveyed possess the ability to read and write in English. Summary of the Problem EMS professionals routinely provide care to patients experiencing significant trauma, pain and suffering. In addition, EMS professionals are subject to an extremely stressful work environment, which places them at high risk for the development of compassion fatigue. Several studies among various health care disciplines have suggested that the implementation of self-care strategies may be effective in the prevention and treatment of compassion fatigue. However, no studies have been conducted evaluating the correlation between the practice of self-care and presence of compassion fatigue among EMS professionals. Identification of potential strategies for prevention and remediation of compassion fatigue within an at-risk group of health care providers will allow for effective and timely intervention, preventing chronic, potentially irreversible physical, professional and emotional consequences. 9 COMPASSION FATIGUE IN EMERGENCY MEDICAL Chapter 2 Review of Related Literature Providing care to patients experiencing pain and suffering has negative effects on the wellbeing of the health care provider. According to Hoffman (as cited in Robinson, 2016) it may result in the inability to feel and express genuine support and empathy. Compassion fatigue has been described as the cost of caring, as it occurs in those who possess a desire to help others who are experiencing crises (Phelps, Lloyd, Creamer, & Forbes, 2009.) Health care providers, such as EMS professionals, have a unique role in that they are the first caregivers summoned in the event of a medical crisis, and therefore have significant exposure to traumatic events which require them to respond empathetically. Those who spend the majority of their careers expressing empathy and caring for others are most at risk for compassion fatigue (Tellie, 2008.) Chapter two provides a review of the current literature regarding compassion fatigue among health care providers. It incorporates the following aspects of the literature: 1. A discussion of compassion fatigue in EMS and fire department personnel 2. A review of the literature related to compassion fatigue in physicians, nurses, and other health care professionals 3. An overview of health promotion and self-care strategies suggested as possible compassion fatigue prevention and management techniques 4. A discussion of the gap in the literature 5. An overview of Conti-O’Hare’s Theory of the Nurse as Wounded Healer Compassion Fatigue in EMS and fire department personnel The concept of compassion fatigue was introduced by Joinson in 1992 as a way of 10 COMPASSION FATIGUE IN EMERGENCY MEDICAL explaining her feelings of emotional devastation from working in the emergency department setting (Lombardo & Eyre, 2011.) EMS and fire department professionals are tasked with the responsibility of caring for patients and family members undergoing significant trauma in an often stressful, chaotic environment. Stressors within the workplace as well as at home, coupled with the lack of self-care, all contribute to the development of compassion fatigue (Wentzel & Brysiewicz, 2014.) A study by Argentero & Setti, 2011, aimed to explore the incidence of symptoms of vicarious traumatization, a term used synonymously with compassion fatigue, and engagement among rescue workers. Similar to compassion satisfaction, engagement refers to the positive feelings experienced by the caregiver, associated with his or her work, which leads to increased involvement and efficacy (Argentero & Setti, 2011.) The study also examined primary predictors of vicarious traumatization and engagement in order to determine factors that may benefit rescue workers. The sample consisted of 782 Italian emergency workers, primarily consisting of ambulance personnel, but also included firefighters, police and other rescue workers, all of which were involved in critical operations, placing them in contact with traumatized subjects. Each participant completed the Maslach Burnout Inventory-General Scale (MBI-GS) as well as the Secondary Traumatic Stress Scale (STSS.) The results of the study indicated that organizational factors, particularly the perceived level of job related support such as role clarity, predictability and support from employer, were contributing factors in the development of engagement and vicarious traumatization (Argentero & Setti, 2011.) This study confirms the compassion satisfaction-compassion fatigue theory, suggested by the Professional Quality of Life Elements 11 COMPASSION FATIGUE IN EMERGENCY MEDICAL Theory and Measurement website, 2017, which indicates that exposure to secondary traumatic stress, coupled with organizational factors that may contribute to burnout, leads to the development of compassion fatigue. High levels of job related support leads to increased compassion satisfaction, which in turn may serve as a preventative measure in the development of compassion fatigue. Another study by Jahnke, Carlos Poston, Haddock, & Murphy, 2016, explored the effects of repeated exposure to trauma (RET) on fire service personnel. This study was a component of a larger qualitative study regarding the health of firefighters which was funded by the American Heart Association. The sample consisted of both volunteer and career firefighters belonging to 34 different fire departments across the nation. Focus groups were led by the fire chief in each department, which addressed perception of wellness, physical fitness, dietary trends among firefighters, tobacco and alcohol use, sleep habits, safety/seatbelt usage, and policies regarding the health of firefighters. Transcriptions of the focus groups were reviewed and evaluated for trends. The results demonstrated that the majority of firefighters suffered negative consequences from repeated exposure to traumatic incidents versus fixation on one specific event. There was a notable trend in firefighters expressing difficulty coping with the repeated exposure to a large quantity of traumatic events due to the nature of their jobs (Jahnke et al., 2016.) The study indicated that while firefighters are negatively impacted by RET, they often adapt and may develop positive coping mechanisms, such as compartmentalization, repeatedly thinking about the event until it becomes less powerful, and engaging in humor with colleagues (Jahnke et al., 2016.) The authors suggest that future research should be conducted to determine 12 COMPASSION FATIGUE IN EMERGENCY MEDICAL the protective factors which contribute to resiliency in this essential population of emergency services personnel. While there are numerous studies regarding compassion fatigue in health care professionals, there are few studies which focus specifically on EMS professionals, further supporting the need for additional studies regarding compassion fatigue among this population. Compassion Fatigue in Nurses and Physicians As with EMS and fire services professionals, nurses, physicians and other professionals within the health care system often find themselves in the position of caring for traumatized and dying patients, as well as their families. Several studies have been identified which explore compassion fatigue within these groups of caregivers. Yoder, 2010, carried out a study that aimed to explore the prevalence of compassion fatigue, circumstances which contribute to its development, as well as coping strategies in this population. The study took place in a 123-bed community hospital in Midwestern United States. The sample consisted of 71 registered nurses working within various specialties of the facility. The participants completed a 3-part questionnaire which consisted of demographics, the Professional Quality of Life Scale (ProQOL) developed by Stamm (1997-2005) and a narrative portion. The study demonstrated that nurses aged 50 and above exhibited a greater incidence of compassion fatigue as well as those employed within the home health and emergency department settings. Nurses who worked 12 hour shifts versus 8 hour shifts and those who had higher levels of education exhibited less compassion fatigue than their counterparts (Yoder, 2010.) Fifty-three percent of nurses identified caring for patients of a particular condition/status, such as those 13 COMPASSION FATIGUE IN EMERGENCY MEDICAL exhibiting challenging behaviors as well as patients with poor prognoses was the greatest influencer in the development of compassion fatigue. System-based issues, such as workload and decisions made by management, were identified by thirty-two percent of the participants as being a major trigger contributing to the presence of compassion fatigue (Yoder, 2010.) The authors also explored the coping mechanism developed by the participants in order to manage compassion fatigue. Fifty-eight percent identified work-related coping mechanisms such as informal debriefing, changing the nature of his or her work involvement, and engaging with colleagues. Forty-two percent indicated that they utilize personal coping mechanisms such as spirituality, placing a greater emphasis on nonwork related engagements, and attitude modification. Awareness of potential triggers which may contribute to the development of compassion fatigue a well as implementation of positive coping strategies may reduce the deleterious effects of compassion fatigue among nurses (Yoder, 2010.) Physicians working in clinical practice are also repeatedly subject to providing care to distressed patients and are often working in undesirable conditions, placing them at risk for the development of compassion fatigue. El-bar et al., 2013, conducted a cross-sectional study to determine the prevalence and significance of compassion fatigue among family practitioners working in the southern region of Israel, Negev. The aim of the study was to explore the correlation between compassion fatigue, burnout and compassion satisfaction and how it relates to socio-demographic variables and work-related circumstances. The study took place at Clalit Health Services Clinics in Negev, where questionnaires including the Professional Quality of Life Scale, were distributed to 194 family physicians. Of the 194 surveys distributed, 128 physicians responded. The results 14 COMPASSION FATIGUE IN EMERGENCY MEDICAL demonstrated that physicians who were born abroad and were not affiliated with any academic institution appeared to have a greater prevalence of compassion fatigue. Higher levels of compassion satisfaction were associated with serving as a preceptor for residents as well as serving in management roles (El-bar et al., 2013.) Limitations of this study include that the study was conducted in an area where a significant percentage of physicians immigrated to Israel from abroad and many had little to no academic affiliation, which represent potential confounding factors. These results, however, may be generalized to other regions due to a large number of foreign-born physicians and international medical school graduates practicing within other nations (El-bar et al., 2013.) Strategies in the Prevention and Management of Compassion Fatigue The negative effects of compassion fatigue on health care providers have been demonstrated in numerous studies. Compassion fatigue contributes to the development of symptoms such as poor decision making, memory impairment, inability to concentrate, sleep disorders, fatigue, myalgias, and loss of interest in activities, all of which negatively impact the health care provider’s wellbeing and patient outcome (Phelps et al., 2009.) Few studies have examined potential preventative measures and interventions in the management of compassion fatigue. In order to develop prevention and treatment strategies, it is necessary to identify factors which may prevent or promote the development of compassion fatigue. According to Phelps et al., 2009, there are various risk factors as well as protective factors associated with the development of compassion fatigue. A study conducted by Boscarino, Figley, & Adams, 2004, examined predicting factors of compassion fatigue and burnout of social workers who provided 15 COMPASSION FATIGUE IN EMERGENCY MEDICAL assistance to people affected by the 9/11/2001 terrorist attack in New York City. A questionnaire was mailed to 600 randomly selected practicing social workers, educated at the master’s level or higher, who were current members of the National Association for Social Workers. The sample consisted of two hundred and thirty-six social workers. Results of the questionnaires indicated a positive correlation between the extent of involvement in the care of these individuals and the experience of secondary traumatization. This suggests that the greater the degree of caregiver involvement, the more likely he or she is to develop secondary traumatization, also known as compassion fatigue. The study also identified a negative correlation between secondary traumatization and working within a supportive environment. A supportive working environment reduces the likelihood of burnout and promotes the development of compassion satisfaction, resulting in a decreased chance of developing compassion fatigue, further reinforcing the relationships demonstrated in Figure 1. Of note, there was a negative correlation between burnout and working within a supportive environment but there was no association between burnout and exposure to traumatized victims. This is consistent with the findings of earlier studies suggesting that burnout is not related specifically to providing care to suffering patients but rather associated with working conditions. Along with risk factors, various protective elements have also been identified within the literature. According to Phelps et al., 2009, serving in a role that requires a frequent empathetic and supportive response due to repeated exposure to the distress and trauma of others, may lead to vicarious traumatization. Therefore, developing and upholding emotional boundaries may serve as a protective strategy against the development of compassion fatigue (Phelps et al., 2009.) Occupational support such as peer support and camaraderie, spirituality, resilience and 16 COMPASSION FATIGUE IN EMERGENCY MEDICAL compassion satisfaction are all protective factors identified in the development of compassion fatigue (Phelps et al., 2009.) Phelps et al., 2009, suggests that incorporating primary prevention strategies, including addressing isolation, inexperience, high work demands, lack of support as well as factors specific to individual workplaces may protect the caregiver from developing compassion fatigue. Secondary prevention tactics include encouraging those who are demonstrating early signs of compassion fatigue to participate in self-screening questionnaires in order to identify their own physical and emotional state, which may otherwise go unnoticed. Self-care strategies such as ensuring a healthy work-life balance, eating a well balance diet, getting adequate sleep, participating in enjoyable activities, taking vacations and breaks, and making time for things which are of value to the caregiver, are also identified as potential strategies for secondary prevention. Tertiary prevention techniques, which include a combination of primary and secondary prevention strategies have been suggested in the literature. These strategies aim to reduce symptoms, prevent worsening of the condition and restore the caregiver’s functioning to the highest possible level, though these suggestions lack clinical validation and require further research (Phelps et al., 2009.) Gap in the Literature While there are numerous studies regarding the effects of compassion fatigue and few exploring preventative strategies in other health care professionals, there are no identified studies evaluating such strategies among EMS professionals. While some existing studies may be generalized to the EMS profession, it is necessary to conduct further research pertaining specifically to this unique, high-risk population that is routinely on the front lines of devastating 17 COMPASSION FATIGUE IN EMERGENCY MEDICAL circumstances, providing care to those in crisis. The existence or implementation of self-care has been proposed as a potentially effective measure in the prevention and treatment of compassion fatigue, though there is limited research that validates this relationship. Theoretical Framework Dr. Marion Conti-O’Hare’s Theory of the Nurse as Wounded Healer served as the theoretical framework for this study. While this theory is aimed at the nursing profession, the aspects of the model which are applicable to nurses are also shared by EMS professionals, in that both roles provide medical care and emotional support to distressed patients. The basis of the model is that nurses as well as other health professionals have all experienced trauma in their lives and are able to transform from walking wounded to a wounded healer by recognizing, transforming and overcoming the pain from trauma. Health care providers are then able to use this growth to be of therapeutic benefit to others (Nurse as Wounded Healer website, 2017.) According to the Nurse as a Wounded Healer website, 2017, the theory assumes the following:  All human beings undergo trauma during their lifetime  For nurses and other health care professionals, this trauma may be of a personal and/or professional nature  The way nurses and other health care professionals cope with this trauma has a significant impact on patient care  Trauma will not resolve spontaneously but rather requires intervention  Trauma can be transformed, transcended, and used to benefit others 18 COMPASSION FATIGUE IN EMERGENCY MEDICAL  Healing occurs with the transformation of oneself from walking wounded to wounded healer  The ability to help others is directly proportional to the degree of transformation and transcendence in a person’s life  The wounded healer is able to provide the greatest therapeutic benefit to others.  The nursing profession as a whole is wounded and must heal itself to survive. The Nurse as a Wounded Healer website, 2017, defines walking wounded as “An individual who remains physically, emotionally and spiritually bound to past trauma. This wounding can be reflected in the nursing practice of the individual in many ways. The walking wounded have limited consciousness related to how their pain is manifested in their lives.” The wounded healer is defined as, “Through self-reflection and spiritual growth, the individual achieves expanded consciousness, through which the trauma is processed, converted and healed” (Nurse as Wounded Healer website, 2017.) According to the Nurse as a Wounded Healer website, 2017, the theory employs the Q.U.E.S.T. Model in order to facilitate healing of the health care professional:  “Question: How has trauma affected my life?”  “Uncover: What can I remember about the major instances or patterns of my personal or professional trauma?”  “Experience: What are my feelings about these events or patterns?”  “Search for Meaning: What do these feelings and experiences mean to me?”  “Transform and Transcend: I change my world view by resolving trauma and becoming a 19 COMPASSION FATIGUE IN EMERGENCY MEDICAL wounded healer.” This model suggests that health care providers are able to recognize and change their current behaviors, in order to recover from past personal and professional trauma. Health care providers may then use this transformation to benefit themselves, their patients and the profession as a whole. The degree to which an individual is capable of facilitating the healing of others relates to his or her self-awareness and personal beliefs (Conti-O’Hare, 2002.) Summary of the Review of Related Literature Due to the nature of their work, EMS professionals are faced with significant daily stressors and repeated exposure to vicarious trauma, placing them at an increased risk for the development of compassion fatigue. Compassion fatigue negatively affects EMS professionals both personally and professionally, resulting in substandard patient care, decreased patient satisfaction and deterioration of the agency’s overall performance. Potential primary, secondary and tertiary prevention of compassion fatigue have been identified in the literature though further research is necessary to expand upon proposed interventions. EMS professionals and managers should be educated on the risk factors and manifestations of compassion fatigue, so that strategies may be implemented to protect this valuable population of healthcare providers. The Theory of the Nurse as a Wounded Healer is applicable to both nurses and EMS professionals and may serve to encourage those suffering from compassion fatigue to adopt health promoting behaviors, such as self-care, to transform from the walking wounded to wounded healers, using this experience to benefit others. Chapter 3 Methodology 20 COMPASSION FATIGUE IN EMERGENCY MEDICAL The purpose of this study was to examine the correlation between the presence of compassion fatigue and implementation of self-care strategies among EMS professionals in Northwestern Pennsylvania. The following chapter describes the research design, setting, sample, instrumentation, data collection, and data analysis. Research Design This study utilized a non-experimental, descriptive, correlational design, intended to determine the relationship between implementation of self-care strategies and presence of compassion fatigue among EMS professionals in Northwestern Pennsylvania. Setting Participants were asked to complete a survey that was accessible via email. The survey was distributed by EMMCO West, the governing body for all EMS professionals working within Northwestern Pennsylvania. Included within the email, was a link that directed the participant to the survey which was administered via survey monkey. The participants had the ability to access and complete the survey from any physical location that allowed for email access. Sample The study utilized a non-probability, convenience sample of EMS professionals. It included both male and female gender, personnel of all ages and years of experience, full and part-time status, serving in paid and/or volunteer roles. The subjects consisted of personnel with active certifications only. Ethical Considerations This research study was subject to the Edinboro University Institutional Review Board (IRB) approval, per the policies of Edinboro University of Pennsylvania. IRB approval from 21 COMPASSION FATIGUE IN EMERGENCY MEDICAL Edinboro University was granted. EMMCO West acknowledged Edinboro University IRB approval upon granting permission to conduct this research via their agency. The researcher has participated in the Collaborative Institutional Training Initiative Research Ethics modules as per Edinboro University guidelines. The data collected via the survey contained no identifiers. The survey was distributed via a link to Survey Monkey, 2017, which included the use of the site’s security infrastructure. An introduction was included within the email, which advised participants of their anonymity and security of responses. Participants were informed of the voluntary nature of his or her participation and of the option to opt out at any time during the completion of the survey. Identifying information was not collected from the participants. Information regarding consent was included in the email. Consent for participation in this study was implied if the participant chose to begin the survey. Instrumentation According to Walker, Sechrist and Pender, 1987, (as cited in Neville & Cole, 2013) The Health Promotion Lifestyle Profile II (HPLP II) is an instrument which was developed in order to measure health promoting behaviors by categorizing lifestyle characteristics. The authors determined that behaviors which promote health consist of physical activity, responsibility for health, spiritual growth, adequate nutrition, stress management, and interpersonal support. All of these behaviors are encompassed within the concept of self-care, which has been proposed to potentially prevent and facilitate the recovery from compassion fatigue. According to Walker & Hill-Polerecky, 1996, “the 52-item HPLP II consists of a total scale and six subscales to measure behaviors in the theorized dimensions of health-promoting 22 COMPASSION FATIGUE IN EMERGENCY MEDICAL lifestyle: spiritual growth, interpersonal relations, nutrition, physical activity, health responsibility, and stress management. Data from 712 adults aged 18 to 92 were used to evaluate validity and reliability. Content validity was established by literature review and content experts' evaluation. Construct validity was supported by factor analysis that confirmed a six-dimensional structure of health-promoting lifestyle, by convergence with the Personal Lifestyle Questionnaire ( r = .678), and by a non-significant correlation with social desirability. Criterion-related validity was indicated by significant correlations with concurrent measures of perceived health status and quality of life ( r's = .269 to .491). The alpha coefficient of internal consistency for the total scale was .943; alpha coefficients for the subscales ranged from .793 to .872. The three-week testretest stability coefficient for the total scale was .892.” This instrument was used to determine the presence of self-care activities which was then correlated with the presence of compassion fatigue. Permission was granted, by the authors of the HPLP II, to utilize this instrument for the purpose of this study. The Professional Quality of Life Scale (ProQOL), version 5, is the most commonly used tool to measure the positive and negative effects of working with people who have experienced traumatic events (Stamm, 2010.) It is a 30-item inventory which utilizes a Likert scale format. The ProQOL consists of 3 subscales, compassion satisfaction, burnout, and secondary traumatic stress, which contribute to the development of compassion fatigue. Using only one of the scales is not recommended, as compassion satisfaction is considered a moderator of compassion fatigue (Stamm, 2010.) Burnout rarely exists at the same time as compassion satisfaction and when both burnout and secondary traumatic stress are present, the most negative outcome is expected (Stamm, 2010.) 23 COMPASSION FATIGUE IN EMERGENCY MEDICAL Over 200 earlier, published studies utilizing the ProQOL have demonstrated good construct validity (Stamm, 2010.) The three scales measure separate constructs. The Compassion Fatigue scale is distinct. The inter‐scale correlations show 2% shared variance (r= -.23; co-ơ =5%; n=1187) with secondary traumatic stress and 5% shared variance (r=-.14; co-ơ = 2%; n=1187) with burnout. While there is shared variance between burnout and secondary traumatic stress the two scales measure different constructs and likely reflect the distress that is shared in both concepts. The shared variance between these two scales is 34% (r=.58; co-ơ = 34%; n=1187.) While both scales measure negative aspects, they are distinct in that the secondary traumatic stress scale evaluates fear while the burnout scale does not (Stamm, 2010.) The ProQOL, version 5, was utilized in this study to evaluate the presence of compassion fatigue, based upon the theoretical relationships of the three subscales: compassion satisfaction, burnout and secondary traumatic stress. Permission was granted, by the authors of the ProQOL, to utilize this instrument for the purpose of this study. Data Collection Responses were collected from EMS professionals that work within Northwestern Pennsylvania. This population was chosen in order to include all certification levels recognized within the state practicing in both volunteer and paid roles, in both rural and metro areas, so that the results may be generalized to other areas practicing under this common model. The aim was to have 100 completed surveys returned for review out of 4,212 EMS professionals in the region. The link to complete the survey via Survey Monkey (2017) was sent to the contact person from EMMCO West for distribution to all EMS professionals with active certification, within Northwestern Pennsylvania. The participants were asked to complete the survey by a specific 24 COMPASSION FATIGUE IN EMERGENCY MEDICAL date. A follow up email was sent one week from the initial distribution which served as a reminder to complete the survey. Permission was obtained from the director of EMMCO West to utilize the Constant Contact system in order to distribute surveys for the purpose of this study. Data Analysis Following the deadline for survey completion, the results were analyzed. Several items on the ProQOL were reversed scored and then a sum of each subscale was obtained. Lastly, the z scores were converted to t-scores with raw score mean = 50 and the raw score standard deviation = 10. Following the scoring of the ProQOL, the results were correlated with the health promotion/self-care practice responses collected via the HPLP II, in order to answer the following research question: Research Question 1: Do EMS professionals in Northwestern Pennsylvania, who practice self-care, experience less compassion fatigue than those who do not? Summary of Methodology This study utilized a non-experimental, descriptive, correlation design, which was intended to determine the correlation between self-care practices and presence of compassion fatigue among EMS professionals. The sample was a non-probability, convenience sample which consisted of EMS professionals working within Northwestern Pennsylvania. It included both male and female EMS professionals of all ages, holding active certification, serving in paid and/or volunteer roles, with varied years of experience. Data was collected utilizing the ProQOL 5 and HPLP II in order to determine the correlation between compassion fatigue and self-care. Chapter 4 Results and Discussion 25 COMPASSION FATIGUE IN EMERGENCY MEDICAL The following chapter presents the results and provides a discussion regarding the outcome of this study. This study was conducted utilizing the ProQOL, version 5, and the HPLP II in order to determine the correlation between self-care and presence of compassion fatigue among EMS professionals working within northwestern Pennsylvania. The ProQOL, version 5, provided data regarding the three subscales that influence the development of compassion fatigue, which consist of: compassion satisfaction, burnout and secondary traumatic stress. Data was also collected via the HPLP II in order to determine the presence of health promoting lifestyle practices, suggestive of self-care. These two instruments comprised the survey which was completed by the nonprobability convenience sample of EMS professionals. Description of the Sample The survey was distributed via the EMMCO West Constant Contact system to 4,212 EMS professionals within northwestern Pennsylvania. Of the 4,212 EMS professionals surveyed, 173 responded resulting in a four percent response rate. Of the 173 EMS professionals who responded, nine completed only the ProQOL and failed to begin the HPLP II. As a result, these nine participants were excluded from the data analysis. Of the remaining 164 participants, 10 failed to complete between one and four items of the survey. To account for these few missing items, the average responses for those questions were calculated and substituted for each corresponding, unanswered item. This data was then utilized in the analysis. Research Question: Do EMS professionals in Northwestern Pennsylvania, who practice self-care, experience less compassion fatigue than those who do not? In order to screen for the presence of compassion fatigue, the ProQOL, version 5, was administered. The ProQOL utilizes 3 subscales to evaluate the presence of compassion 26 COMPASSION FATIGUE IN EMERGENCY MEDICAL satisfaction, burnout and secondary traumatic stress, all of which influence the development of compassion fatigue. Based on the responses to the ProQOL (N=164), each participant’s answers were scored and placed within one of three categories: low, average, high. In order to assign each category, items 1, 4, 15, 17 and 29 were reversed scored, raw data was converted into zscores which were then converted into t-scores. Participants scoring less than or equal to 43.5 were included in the low category, those scoring between 43.6 and 56.5 were included in the average category, while those scoring greater than or equal to 56.6 were assigned to the high category. Each range was then converted into a numeric score ranging from one to three, with a score of one representing the low category of compassion fatigue, two representing the average category of compassion fatigue and three representing the high category of compassion fatigue. In order to determine the presence of a health promoting lifestyle/participation in selfcare, the HPLP was scored and the mean was obtained resulting in a possible value between 52 and 208. This ordinal data was then converted into interval data and ranked either one, two, three or four, representing those who never, sometimes, often or routinely practice self-care, respectively. Categories of each compassion fatigue component were then correlated with rank of selfcare practice utilizing Spearman’s rank correlation coefficient (rho.) A value of rho ranging from .10 to .29 represents a small correlation, a rho of .30 to .49 indicates a moderate correlation and a rho of .50 to 1.0 indicates a strong correlation. The direction of the correlation is based upon the negative or positive nature of the correlation coefficient. A negative coefficient indicates that there is a negative correlation between the two variables. A positive coefficient represents a positive correlation between the two variables. 27 COMPASSION FATIGUE IN EMERGENCY MEDICAL There was a moderately strong positive correlation between compassion satisfaction and self-care practices, indicating that those who practice self-care tend to have higher levels of compassion satisfaction. There was a strong negative correlation noted between burnout and self-care practices, indicating that those who practice self-care tend to experience markedly lower levels of burnout. Finally, there was a moderately strong, negative correlation between secondary traumatic stress and self-care, suggesting that those who practice self-care tend to have lower levels of secondary traumatic stress. Based upon the results of this study, those who practiced self-care reported higher levels of compassion satisfaction, low levels of burnout and low levels of secondary traumatic stress. In order to develop compassion fatigue, a person must experience secondary traumatic stress in the setting of burnout, with a potential absence or low level of compassion satisfaction (Professional Quality of Life Elements Theory and Measurement website, 2017.) The data collected from this study supports this theory and therefore it may be inferred that those who practice self-care are likely not suffering from compassion fatigue. Table 1: Component of Compassion Fatigue vs Self-care Component of Compassion Fatigue Compassion Satisfaction Correlation Coefficient Significance (p) N Burnout Correlation Coefficient Significance (p) N Secondary Traumatic Stress Correlation Coefficient Significance (p) N Average Health Promoting Lifestyle/Self-care Practices .493 .000 164 -.619 .000 164 -.321 .000 164 28 COMPASSION FATIGUE IN EMERGENCY MEDICAL This information was further reduced into specific categories of self-care, by obtaining the mean to a particular subset of questions and scoring via the same method utilized to obtain an overall score for a health promoting lifestyle/participation in self-care. As recommended by the authors of the HPLP II, the means rather than sums of scale items were utilized in order to retain the 1 to 4 metric of item responses as well as to allow for meaningful comparisons of scores across each subscale. This resulted in a score for the following subscales: physical activity, nutrition, spiritual growth, interpersonal relations, stress management and health responsibility. Health responsibility, according to the HPLP II, includes actions such as consulting with health care professionals regarding unusual symptoms, obtaining second opinions from health care providers when needed, working to improve health literacy and participating in health maintenance activities. Each component that comprises the concept of compassion fatigue was then correlated with rank of each category of self-care, utilizing Spearman’s rank correlation coefficient (rho.) A small but statistically significant positive correlation was noted between compassion satisfaction and the categories of self-care: physical activity and nutrition. A moderate, positive correlation was noted between compassion satisfaction and self-care categories: health responsibility and stress management. There was a strong, positive correlation between compassion satisfaction and self-care categories: interpersonal relations and spiritual growth. There was a moderate, negative correlation between burnout and self-care categories: health responsibility, physical activity, and nutrition. A strong, negative correlation was noted between burnout and self-care categories: spiritual growth, interpersonal relations, and stress management. Finally, a small but statistically significant, negative correlation was noted 29 COMPASSION FATIGUE IN EMERGENCY MEDICAL between secondary traumatic stress and self-care categories: health responsibility, interpersonal relations, and nutrition. There was a small, negative correlation between secondary traumatic stress and physical activity, however this relationship was not statistically significant. There was a moderate, negative correlation noted between secondary traumatic stress and self-care categories: spiritual growth and stress management. Table 2: Component of Compassion Fatigue vs Categories of Self-care Component of Compassion Fatigue Health Responsibility Physical Activity Nutrition Spiritual Growth Interpersonal Stress Relations Management Compassion Satisfaction Correlation Coefficient Significance (p) N Burnout Correlation Coefficient Significance (p) N Secondary Traumatic Stress Correlation Coefficient Significance (p) N .373 .278 .213 .582 .534 .354 .000 163 -.385 .000 163 -.375 .006 163 -.367 .000 158 -.662 .000 162 -.556 .000 163 -.560 .000 163 -.197 .000 163 -.056 .000 163 -.183 .000 158 -.399 .000 162 -.293 .000 163 -.330 .012 163 .474 163 .019 163 .000 158 .000 162 .000 163 In order to suffer from compassion fatigue, the EMS professional must have exposure to secondary trauma in the setting of burnout. Rarely, does compassion satisfaction occur simultaneously with burnout and therefore those participants with high levels of compassion satisfaction are unlikely to be experiencing compassion fatigue. Of the responses, those who implement health promoting lifestyle or self-care activities experience high levels of compassion 30 COMPASSION FATIGUE IN EMERGENCY MEDICAL satisfaction, low levels of burnout and low levels of secondary traumatic stress and are therefore unlikely to be suffering from compassion fatigue. The opposite of this is also true, in that those who are not practicing self-care have lower levels of compassion satisfaction, higher levels of burnout and higher levels of secondary traumatic stress indicating the presence of compassion fatigue. Based upon the results of this study and interpretation of data in accordance with the CF-CS model (Professional Quality of Life Elements Theory and Measurement website, 2017), it may be inferred that EMS professionals in Northwestern Pennsylvania, who practice self-care, experience less compassion fatigue than those who do not. Summary The research question examined whether EMS professionals in Northwestern Pennsylvania, who practice self-care, experience less compassion fatigue than those who do not. Based upon the outcome of the data analysis, it was determined that there is a positive correlation between self-care and compassion satisfaction, with a negative correlation between self-care and both burnout and secondary traumatic stress. These findings, interpreted with consideration of the theory demonstrated in the CS-CF model, indicate a negative correlation between self-care and compassion fatigue, which was statistically significant at p < .05. The results also indicate that all forms of self-care evaluated in the study are negatively correlated with compassion fatigue, all of which were statistically significant with the exception of the relationship between secondary traumatic stress and physical activity. Identifying this negative correlation between self-care activities and compassion fatigue will allow for further efforts in the development of compassion fatigue prevention and treatment strategies. 31 COMPASSION FATIGUE IN EMERGENCY MEDICAL Chapter 5 Summary, Conclusions, and Recommendations Interpretation of the Findings The purpose of this study was to determine if EMS professionals in Northwestern Pennsylvania, who practice self-care, experience less compassion fatigue than those who do not. The study was conducted via survey which included two published instruments, the ProQOL, version 5, which served as a screening tool for compassion fatigue and the HPLP II, which evaluated the presence of self-care. The survey link was distributed to 4,212 EMS professionals in Northwestern Pennsylvania, by the EMMCO West Constant Contact system, with 164 EMS professionals choosing to participate in the study by returning a completed survey. The survey was completed anonymously via survey monkey over a two-week period. While there were several limitations to this study which may encourage the development of future research, this study determined that those EMS professionals surveyed, who practice self-care, experience higher levels of compassion satisfaction, lower levels of burnout and lower levels of secondary traumatic stress compared with those who do not. As indicated by the theory regarding the development of compassion fatigue, as demonstrated in the CS-CF model, those who experience high levels of compassion satisfaction, low levels of burnout and low levels of secondary traumatic stress are unlikely to experience compassion fatigue. Therefore, based upon the results of this study, it may be inferred that those who practice self-care are less likely to experience compassion fatigue versus those who do not. A second analysis was performed which evaluated the relationship between compassion satisfaction, burnout and secondary traumatic stress and the specific categories of self-care 32 COMPASSION FATIGUE IN EMERGENCY MEDICAL measured via the HPLP II: health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management. The data from each individual category of selfcare revealed a positive correlation between participation in the activity and presence of compassion satisfaction and a negative correlation between participation and presence of both burnout and secondary traumatic stress. The negative correlation between physical activity and secondary traumatic stress was not statistically significant, however, given the positive correlation between compassion satisfaction and physical activity and negative correlation with burnout, it remains unlikely that this group is experiencing compassion fatigue, as compassion fatigue is thought to occur in the setting of burnout and secondary traumatic stress with an absence of compassion satisfaction. These findings further support previous findings in the literature, as discussed in Chapter two. Those who demonstrated spiritual growth and interpersonal relations indicated high levels of compassion satisfaction, as well as low levels of both burnout and secondary traumatic stress, which suggest low levels of compassion fatigue. These findings are consistent with those identified by Phelps et al., 2009, suggesting that peer support and camaraderie, spirituality, and compassion satisfaction are all factors which protect an individual from the development of compassion fatigue. In addition, Phelps et al., suggests healthy work-life balance, eating a well balance diet, getting adequate sleep, participating in enjoyable activities, taking vacations and breaks, and making time for things which are of value to the caregiver, serve as potential strategies in the treatment of compassion fatigue. The data from this study supports this hypothesis, in that participation in good nutrition and stress management activities, which included achievement of adequate sleep, participation in relaxation techniques, making time for 33 COMPASSION FATIGUE IN EMERGENCY MEDICAL recreational activities and having a healthy balance between work and play, resulted in a negative correlation with the presence of compassion fatigue. Theoretical Framework Dr. Marion Conti-O’Hare’s, Theory of the Nurse as Wounded Healer, served as the theoretical framework for this study. As discussed in Chapter two, this theory assumes that all healthcare professionals undergo trauma, personal and/or professional, which affects both the caregiver as well as the patient (Nurse as Wounded Healer website, 2017.) It is suggested that through recognition of this trauma and implementation of an effective intervention, it is possible to transcend from walking wounded to wounded healer. As a wounded healer, the caregiver is able to use this transformation to benefit others by improving one’s ability to demonstrate empathy, develop a rapport and provide unconditional support (Conti-O’Hare, 2002.) This model emphasizes that without intervention, the trauma experienced by the caregiver will not resolve (Nurse as Wounded Healer website, 2017.) This is significant because according to Boyle, 2011, as discussed in Chapter one, compassion fatigue, without early identification and treatment, may result in the caregiver’s permanent inability to provide care and demonstrate compassion for others. Suffering from compassion fatigue not only negatively impacts the caregiver’s ability to provide patient care but also the overall outcome of the patient (Rosenstein, 2013.) Identification and treatment of compassion fatigue may allow for the EMS professional to transcend from walking wounded to wounded healer, at which time he or she may use this experience of overcoming one’s trauma to strengthen his or her ability to establish a rapport with patients, show empathy and compassion as well as improve patient outcomes. It has been 34 COMPASSION FATIGUE IN EMERGENCY MEDICAL suggested in the literature and supported by the results of this study, that self-care may serve a role in the prevention and treatment of compassion fatigue. With the implementation of self-care activities, those EMS professionals suffering from compassion fatigue, may be able to recover from this trauma and use this experience of transcending from walking wounded to wounded healer to provide therapeutic benefit to their patients. Dr. Marion Conti-O’Hare has suggested that the nursing profession is wounded and must heal itself so that it may survive (Conti-O’Hare, 2002.) This may also be true for the EMS profession. EMS professionals are at great risk for compassion fatigue, as they are required to care for others in times of tragedy and crisis. They repeatedly witness traumatic events, pain, and suffering of others. They are part of a profession that does not readily promote self-care as they are often required to work long hours, face increasingly high demands, carry out life-saving work without adequate staffing levels, receive low financial compensation and are often not provided with adequate rest and meal breaks (Jacobs, Heller, Waheed, & Appel, 2017.) In order for the EMS profession to survive, EMS professionals and industry leaders must recognize the importance of improving compassion satisfaction and reducing burnout as well as secondary traumatic stress, thereby promoting prevention and treatment of compassion fatigue. Self-care has been suggested in the literature and supported by the results of this study, as a potential method that may increase compassion satisfaction, reduce burnout and secondary traumatic stress, which may ultimately serve as an intervention to prevent and treat compassion fatigue. Limitations There were several limitations to this study. One limitation is that demographic information, which may have provided further insight into potential confounding variables, was 35 COMPASSION FATIGUE IN EMERGENCY MEDICAL not collected for this study. The respondents all work within Northwestern Pennsylvania which may potentially skew data based upon factors unique to emergency medical services in that particular geographical location. This study identifies a correlation between variables and does not necessarily indicate causality, which may also represent a limitation. Lastly, it is theorized that compassion fatigue develops as a result of the influence from three factors, compassion satisfaction, burnout and secondary traumatic stress, rather than a single variable. These three components are measured and scored via the ProQOL, the most commonly utilized instrument in screening for compassion fatigue. The importance of screening for compassion fatigue based upon all three of these components versus one particular variable is stressed by the authors of the ProQOL. However, from a statistical standpoint, this may be considered a potential limitation as this screening tool does not provide a direct measure of a single variable, compassion fatigue, but rather allows for an inference to be made based upon the relationship of the three variables which are theorized to either result in or provide protection from the development of compassion fatigue. Recommendations for Future Research This study supports the need for further research regarding the influence of self-care on compassion fatigue. While a correlation was identified that suggests self-care may influence the development of compassion fatigue, interventional studies are needed to evaluate the direct impact of self-care on compassion fatigue. Studies that include a larger sample size, representing a larger geographical area, and encompass a variety of EMS operational models, may facilitate the generalization of findings. In addition to conducting a similar study which evaluates demographics of respondents, it may also be of benefit to determine the presence of pre-existing 36 COMPASSION FATIGUE IN EMERGENCY MEDICAL mental health issues, such as anxiety and depression, as well as personality traits that may represent predisposing factors in the development of compassion fatigue. Furthermore, expanding this research to evaluate characteristics which may offer protection from compassion fatigue, such as resiliency, could provide further insight into identification of at risk populations and lead to the development of individualized treatment strategies. Implications for EMS Professionals As previously stated, compassion fatigue has deleterious effects which negatively affect both the caregiver and patient. Due to the nature of their work, EMS professionals are at great risk for the development of compassion fatigue. Identification of preventative or remedial strategies are imperative in order to improve the lives of those who are at risk for or currently suffering from compassion fatigue, as well as the patients for whom they are providing care. The results of this study indicate that EMS professionals who practice self-care exhibit lower levels of compassion fatigue, suggesting this strategy as a potential preventative and/or treatment method. EMS professionals must first be aware of the concept of compassion fatigue, as well as its negative consequences on the caregiver and the patients they serve. An organization’s leadership has the ability to promote compassion fatigue awareness so that employees are familiar with the concept and have knowledge of where they may seek assistance, if needed. In the absence of awareness and identification of those suffering from compassion fatigue, prevention and intervention strategies are not relevant. Screening for compassion fatigue may be done via various free instruments, such as the ProQOL, which can be completed and scored by the participant so that EMS professional may be aware of his or her own personal risk. It is 37 COMPASSION FATIGUE IN EMERGENCY MEDICAL important that EMS agencies recognize compassion fatigue as a potential consequence of working within the EMS setting and foster an environment that promotes acceptance and understanding of an individual who may be suffering from compassion fatigue, in the same manner that a physical injury may be acknowledged. There is often great attention given to prevention of physical injuries in EMS, such as education and training regarding proper lifting techniques in order to prevent back injuries. A similar focus should be given to prevention of compassion fatigue, as it also has significant, negative consequences for both the EMS professional and agency. The results of this study indicate that self-care may be a potential method of preventing and/or treating compassion fatigue. Self-care activities such as practicing good nutrition, taking part in physical exercise, achieving adequate sleep and practicing relaxation techniques in order to manage stress are lifestyle changes that can be easily implemented without great expense or adverse effects. These changes can occur at both the individual and organizational level and may significantly improve the EMS professional’s quality of life, patient outcome and overall agency performance. At the individual level, EMS professionals can independently initiate self-care activities which meet their individual preferences and lifestyles, which may improve consistency and sustainability. Organizations may opt to implement activities which encourage healthy lifestyle changes such as the development of sports teams, on-site gym equipment, yoga classes, gym memberships at a reduced, corporate cost, employee assistance programs which provide counseling services, social outings, wellness plans, as well as mandatory down time and meal break policies to allow for adequate rest and nutrition. For departments which have financial constraints, there are circumstances where grant money may be used toward improvement of 38 COMPASSION FATIGUE IN EMERGENCY MEDICAL employee health within EMS and fire service. This study provides further insight into potential preventative and treatment strategies for compassion fatigue, specifically among EMS professionals. The results of this study suggest that self-care may be a potentially effective method within this group of at-risk professionals. However, additional research, including interventional studies, are required to further evaluate the relationship between self-care and compassion fatigue among EMS professionals. Conclusion EMS professionals are frequently required to provide care to suffering patients undergoing crises, which places them at great risk for the development of compassion fatigue. Repeated exposure to these circumstances may lead the EMS professional to vicariously experience a similar trauma to that of the patient, resulting in various physical, psychological, and spiritual consequences, eventually exhausting his or her ability to show compassion for others. The findings of this study are unique and significant because while there have been numerous studies evaluating compassion fatigue among other health care disciplines, few studies were identified that evaluate compassion fatigue in EMS professionals. In addition, there were no studies noted that evaluate preventative strategies or treatment interventions, such as self-care, within this at-risk population. As a result of this gap in the literature, this study was developed and carried out in order to determine if EMS professionals in Northwestern Pennsylvania, who practice self-care, experience less compassion fatigue than those who do not. The results of this study indicate that the EMS professionals surveyed, who practice selfcare, experience higher levels of compassion satisfaction, lower levels of burnout and lower levels of secondary traumatic stress, indicating low levels of compassion fatigue. 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Retrieved from https://www.academia.edu/4130142/boscarino_IJEMH Boyle, D. A. (2011). Countering compassion fatigue: A requisite nursing agenda. Online Journal of Issues in Nursing, 16(1). http://dx.doi.org/10.3912/OJIN.Vol16No01Man02 Bruner, V., & Rhodes, J. (n.d.). Understanding and overcoming compassion fatigue [PowerPoint slides]. Retrieved from Navy Medicine website: http://www.med.navy.mil/sites/nmcphc/Documents/health-promotion-wellness/woundedill-and-injured/understanding-overcoming-compassion-fatigue.pdf Bush, N. (2009). Compassion fatigue: Are you at risk? Oncology Nursing Forum, 36(1), 24-28. http://dx.doi.org/10.1188/09.ONF.24-28 Coetzee, S. K., & Klopper, H. C. (2010). Compassion fatigue within nursing practice: A concept analysis. Nursing & Health Sciences, 12(2), 235-243. http://dx.doi.org/10.1111/j.14422018.2010.00526.x 41 COMPASSION FATIGUE IN EMERGENCY MEDICAL Conti-O’Hare, M. (2002). The nurse as wounded healer: From trauma to transcendence. Sudbury, Massachusetts: Jone and Bartlett. Crim, E. R. (2017, June 1). Provider self-care through conscious, balanced relationships. Counselor: The Magazine for Addiction Professionals, 18(3), 53-58. Retrieved from http://www.counselormagazine.com El-bar, N., Levy, A., Wald, H. S., & Biderman, A. (2013, August 15). Compassion fatigue, burnout and compassion satisfaction among family physicians in the Negev area-A cross sectional study. Israel Journal of Health Policy Research, 2(1), 31. http://dx.doi.org/10.1186/2045-4015-2-31 Health care provider. (2002). In McGraw-Hill Concise Dictionary of Modern Medicine. Retrieved from http:/medical-dictionary.thefreedictionary.com Henson, J. S. (2017, March/April). When compassion is lost. MEDSURG Nursing, 26(2), 139142. Retrieved from https://www.amsn.org Jacobs, K., Heller, N., Waheed, S., & Appel, S. (2017). Emergency medical services in California: Wages, working conditions, and industry profile. Retrieved from http://laborcenter.berkeley.edu Jahnke, S. A., Carlos Poston, W. S., Haddock, C. K., & Murphy, B. (2016). Firefighting and mental health: Experiences of repeated exposure to trauma. Work, 53(4), 737-744. http://dx.doi.org/10.3233/WOR-162255 Lombardo, B., & Eyre, C. (2011). Compassion fatigue: A nurse’s primer. OJIN: The Online Journal of Nursing, 16(1). Retrieved from www.nursingworld.org 42 COMPASSION FATIGUE IN EMERGENCY MEDICAL Meinecke, C. (2010). Self-care in a toxic world. Retrieved from https://www.psychologytoday.com/blog/everybody-marries-the-wrongperson/201006/self-care-in-toxic-world National Highway Traffic Safety Administration. (2007). National EMS scope of practice model. Retrieved from https://www.ems.gov/education/EMSScope.pdf Neville, K., & Cole, D. A. (2013). The relationship among health promotion behaviors, compassion fatigue, burnout and compassion satisfaction in nurses practicing in a community medical center. The Journal of Nursing Administration, 43(6), 348-354. http://dx.doi.org/10.1097/NNA.0b013e3182942c23 Nurse as Wounded Healer website. (2017). http://www.drmarioncontiohare.com/ Phelps, A., Lloyd, D., Creamer, M., & Forbes, D. (2009, February). Caring for carers in the aftermath of trauma. Journal of Agression, Maltreatment & Trauma, 18, 313-330. http://dx.doi.org/10.1080/10926770902835899 Professional Quality of Life Elements Theory and Measurement website. (2017). proqol.org Robinson, T. M. (2016). Predictive factors of compassion fatigue among firefighters (Doctoral dissertation, Walden University). Retrieved from http://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=3435&context=dissertations Rosenstein, A. H. (2013, August 15). Addressing physician stress, burnout, and compassion fatigue: The time has come. Israel Journal of Health Policy Research, 2(32). http://dx.doi.org/10.1186/2045-4015-2-32 Sodeke-Gregson, E. A., Holttum, S., & Billings, J. (2013, December 30). Compassion satisfaction, burnout, and secondary traumatic stress in UK therapists who work with 43 COMPASSION FATIGUE IN EMERGENCY MEDICAL adult trauma clients. European Journal of Psychotraumatology, 4. http://dx.doi.org/10.3402%2Fejpt.v4i0.21869 Stamm, B. (2010). The concise ProQOL Manual (2nd ed.). Retrieved from http://www.proqol.org Tellie, M. (2008). Compassion fatigue: The cost of caring. Nursing Update, 32(8), 34-37. Retrieved from http://library.gcu.edu The American Institute of Stress website. (2017). https://www.stress.org Thompson, A. (2013, July). How Schwartz rounds can be used to combat compassion fatigue. Nursing Management, 20(4), 16-20. Retrieved from http://journals.rcni.com/journal/nm Walker, S. N., & Hill-Polerecky, D. M. (1996). Psychometric evaluation of the health promoting lifestyle profile II. Unpublished manuscript, University of Nebraska Medical Center. Retrieved from https://www.unmc.edu/nursing/faculty/HPLPII_Abstract_Dimensions.pdf Wentzel, D., & Brysiewicz, P. (2014, January). The consequence of caring too much: Compassion fatigue and the trauma nurse. Journal of Emergency Nursing, 40(1), 95-97. Retrieved from www.jenonline.org Yoder, E. (2010). Compassion fatigue in nurses. Applied Nursing Research, 23(4), 191-197. http://dx.doi.org/10.1016/j.apnr.2008.09.003 44 COMPASSION FATIGUE IN EMERGENCY MEDICAL Appendices Appendix A: Permission Letter from EMMCO West To: Edinboro University of PA IRB Review Panel Edinboro, PA From: William D. McClincy Executive Director Date: October 12, 2017 Ref.: Kelly Martin’s Research Project Survey Request EMMCO West, Inc. is the regional emergency medical services (EMS) office for seven Northwest PA counties. These include Clarion, Crawford, Erie, Forest, Mercer, Venango, and Warren counties. EMMCO West is a contracted grant recipient for the PA Department of Health, Bureau of EMS. As part of our customer service outreach, we use an online email server (ConstantContact). We use ConstantContact to communicate EMS system information to EMS agencies and EMS practitioners. Our email server has access to over 4,000 email accounts. Ms. Kelly Martin has requested permission and assistance from EMMCO West to send out a survey that is related to her research initiative. The title of her research project is “Compassion fatigue in emergency medical services (EMS): The influence of self-care on compassion fatigue among EMS professionals in Northwestern Pennsylvania”. EMMCO West, Inc., as part of our work statement of activities with the PA Department of Health, is to assist with EMS prehospital research initiatives. Ms. Martin’s request falls within our work statement parameters. EMMCO West, Inc. will provide assistance through the use of the ConstantContact email system to distribute her online survey for this research initiative. Feel free to contact me if you have any questions or need additional information. 45 COMPASSION FATIGUE IN EMERGENCY MEDICAL Appendix B: Permission to use the ProQOL, version 5 Permission for Use of the ProQOL (Professional Quality of Life Scale: Compassion Satisfaction and Compassion Fatigue) www.proqol.org Accompanied by the email to you, this document grants you permission to use for your study or project The ProQOL (Professional Quality of Life Scale: Compassion Satisfaction and Compassion Fatigue) www.ProQOL.org Prior to beginning your project and at the time of any publications, please verify that you are using the latest version by checking the website. All revisions are posted there. If you began project with an earlier version, please reference both to avoid confusion for readers of your work. This permission covers non-profit, non-commercial uses and includes permission to reformat the questions into a version that is appropriate for your use. This may include computerizing the measure. Please print the following reference or credit line in all documents that include results gathered from the use of the ProQOL. Stamm, B. H. (2010). The ProQOL (Professional Quality of Life Scale: Compassion Satisfaction and Compassion Fatigue). Pocatello, ID: ProQOL.org. retrieved [date] www.proqol.org Permission granted by Beth Hudnall Stamm, PhD Author, ProQOL ProQOL.org info@proqol.org Help us help all of us. Please consider donating a copy of your raw data to the data bank. You can find more about the data bank and how you can donate at www.proqol.org and www.proqol.org/Donate_Data.html. Data donated to the ProQOL Data Bank allow us to advance the theory of compassion satisfaction and compassion fatigue and to improve and norm the measure itself. 46 COMPASSION FATIGUE IN EMERGENCY MEDICAL Appendix C: Permission to Use the HPLP II Dear Colleague: Thank you for your interest in the Health-Promoting Lifestyle Profile II. The original Health-Promoting Lifestyle Profile became available in 1987 and has been used extensively since that time. Based on our own experience and feedback from multiple users, it was revised to more accurately reflect current literature and practice and to achieve balance among the subscales. The Health-Promoting Lifestyle Profile II continues to measure healthpromoting behavior, conceptualized as a multidimensional pattern of self-initiated actions and perceptions that serve to maintain or enhance the level of wellness, self-actualization and fulfillment of the individual. The 52-item summated behavior rating scale employs a 4-point response format to measure the frequency of self-reported health-promoting behaviors in the domains of health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations and stress management. It is appropriate for use in research within the framework of the Health Promotion Model (Pender, 1987), as well as for a variety of other purposes. The development and psychometric evaluation of the English and Spanish language versions of the original instrument have been reported in: Walker, S. N., Sechrist, K. R., & Pender, N. J. (1987). The Health-Promoting Lifestyle Profile: Development and psychometric characteristics. Nursing Research, 36(2), 76-81. Walker, S. N., Volkan, K., Sechrist, K. R., & Pender, N. J. (1988). Health-promoting lifestyles of 47 COMPASSION FATIGUE IN EMERGENCY MEDICAL older adults: Comparisons with young and middle-aged adults, correlates and patterns. Advances in Nursing Science, 11(1), 76-90. Walker, S. N., Kerr, M. J., Pender, N. J., & Sechrist, K. R. (1990). A Spanish language version of the HealthPromoting Lifestyle Profile. Nursing Research, 39(5), 268-273. Copyright of all versions of the instrument is held by Susan Noble Walker, EdD, RN, FAAN, Karen R. Sechrist, PhD, RN, FAAN and Nola J. Pender, PhD, RN, FAAN. The original Health-Promoting Lifestyle Profile is no longer available. You have permission to download and use the HPLPII for non-commercial data collection purposes such as research or evaluation projects provided that content is not altered in any way and the copyright/ permission statement at the end is retained. The instrument may be reproduced in the appendix of a thesis, dissertation or research grant proposal. Reproduction for any other purpose, including the publication of study results, is prohibited. A copy of the instrument (English and Spanish versions), scoring instructions, an abstract of the psychometric findings, and a list of publications reporting research using all versions of the instrument are available for download. Sincerely, Susan Noble Walker, EdD, RN, FAAN Professor Emeritus 48 COMPASSION FATIGUE IN EMERGENCY MEDICAL Appendix D: Edinboro University IRB Approval Letter This memo provides the notification concerning EU's Institutional Review Board (IRB) determination of the human subjects protocol: To: Dr. Terri Astorino, Principal Investigator; Kelly Martin, Co-Investigator From: Elisabeth Joyce, Edinboro University Institutional Review Board Chair Protocol # EU201748 Date Approved: 13-Oct-2017 Title: Compassion Fatigue in Emergency Medical Services (EMS): The Influence of Self-Care on Compassion Fatigue among EMS Professionals in Northwestern Pennsylvania The EU IRB Chair has designated this committee as reviewer of the application listed above for exempt status. It has been determined that your protocol is categorized as Exempt under federal regulations 45 CFR 46.101(b), since the research design involves one or more of the following criteria: ___Research conducted in established or commonly accepted educational settings, involving normal educational practices. _X_Research using educational tests, surveys or interviews where respondents are not identified or are public officials. ___Research involving observation of public behavior. ___Research involving collection, study, and use of existing data where subjects are not identified. Exempt protocol means that as long as you continue your research as described in your protocol application, the research does not require any further review or oversight by the IRB. Should you change any procedure within your research, you are 49 COMPASSION FATIGUE IN EMERGENCY MEDICAL required to resubmit the protocol to the IRB for reconsideration and determination before you implement any change. All data must be retained and accessible for three (3) years after the completion of the project. Designation as exempt signifies only that the proposal adequately qualifies under 45 CFR 46.101(b) for such status. It does not imply, directly or indirectly, any institutional support or permission to conduct the study. Should you have any questions or concerns, please feel free to contact me at 814-7322448. 50 COMPASSION FATIGUE IN EMERGENCY MEDICAL Appendix E: Collaborative Institutional Training Initiative (CITI) Certificates 51 COMPASSION FATIGUE IN EMERGENCY MEDICAL 52 COMPASSION FATIGUE IN EMERGENCY MEDICAL 53 COMPASSION FATIGUE IN EMERGENCY MEDICAL Appendix F: Consent to Participate in Research Study/Survey EDINBORO UNIVERSITY OF PENNSYLVANIA Edinboro, Pennsylvania CONSENT TO PARTICIPATE IN A RESEARCH STUDY Title of Study: Compassion fatigue in emergency medical services (EMS): The influence of selfcare on compassion fatigue among EMS professionals in Northwestern Pennsylvania Principal & Co- investigators: Dr. Terri Astorino and Kelly Martin Introduction You are being asked by Kelly Martin to be in a research survey. This consent describes your role as a participant in the survey. This research is part of the requirements for a Doctorate in Nursing Practice degree at Clarion and Edinboro Universities. Study Purpose The purpose of this study is to determine the correlation between self-care and compassion fatigue among EMS professionals in Northwestern Pennsylvania. What Will Happen During the Study? After reviewing the consent form, you will be given the opportunity to choose to participate in the survey by clicking the “next” button. If you choose to not participate, just exit out of your web browser. The time to complete the survey is estimated to be approximately 20 minutes. What Are the Possible Risks or Discomforts? No demographic information will be collected, however, anonymity remains a potential risk to the participant. In order to minimize the risk to the participant, no personal identifiers will be collected by the researchers. This study will utilize Survey Monkey as the instrument by which data will be collected. Survey Monkey employs security measures to maintain anonymity as outlined in their security statement and privacy policy. What Are the Possible Benefits of Participating in This Study? This research will benefit emergency medical services as a whole as well as the patients served. By identifying the correlation between self-care and compassion fatigue, awareness programs and other interventions may be implemented to prevent or remediate the negative impact of compassion fatigue on EMS professionals. How Will the Collected Data Be Kept Confidential? Personal identifiers will not be collected. The researchers will disable the storage of email or IP addresses. Survey Monkey provides a security infrastructure which includes SSL/TLS encryption. Only the researchers will have access to the survey. Data will be 54 COMPASSION FATIGUE IN EMERGENCY MEDICAL retained for three years and will then be destroyed via a permanent deletion option provided by Survey Monkey. What Happens If I Have More Questions? Your questions about a research-related injury or the research study will be answered by Dr Terri Astorino at tastorino@edinboro.edu. If you have a question about your rights as a research participant you can contact the chairperson of Edinboro University Institutional Review Board, at irb-chair@edinboro.edu What Will Happen If You Decide Not To Be in the Study? Your participation is strictly voluntary; you may elect not to answer any or all of the questions in the survey. If you change your mind about participating, there will be no penalty, retribution, or repercussion for withdrawing from the study. To stop taking the survey, exit out of your web browser. By clicking the next button and beginning the survey, you acknowledge that you have read the informed consent and agree to participate in the survey. You also acknowledge that you are at least 18 years of age and that you understand that you have the right not to answer any or all of the questions in the survey. Finally, you understand that you can quit the survey, without penalty, at any time. 55 COMPASSION FATIGUE IN EMERGENCY MEDICAL Appendix G: Permission to Utilize Survey Monkey for Research Study SurveyMonkey Inc. www.surveymonkey.com For questions, visit our Help Center help.surveymonkey.com Re: Permission to Conduct Research Using SurveyMonkey To whom it may concern: This letter is being produced in response to a request by a student at your institution who wishes to conduct a survey using SurveyMonkey in order to support their research. The student has indicated that they require a letter from SurveyMonkey granting them permission to do this. Please accept this letter as evidence of such permission. Students are permitted to conduct research via the SurveyMonkey platform provided that they abide by our Terms of Use, a copy of which is available on our website. SurveyMonkey is a self-serve survey platform on which our users can, by themselves, create, deploy and analyze surveys through an online interface. We have users in many different industries who use surveys for many different purposes. One of our most common use cases is students and other types of researchers using our online tools to conduct academic research. If you have any questions about this letter, please contact us through our Help Center at help.surveymonkey.com. 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