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Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
Development of the Emergency Medical Services Role Identity Scale (EMS-RIS) a
Elizabeth A. Donnelly PhD, LICSW, MPH, NREMT , Darcy Siebert PhD & Carl Siebert PhD, MBA
b
b
a
School of Social Work, University of Windsor, Windsor, Ontario, Canada b
School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA Published online: 11 Mar 2015.
Click for updates To cite this article: Elizabeth A. Donnelly PhD, LICSW, MPH, NREMT, Darcy Siebert PhD & Carl Siebert PhD, MBA (2015) Development of the Emergency Medical Services Role Identity Scale (EMS-RIS), Social Work in Health Care, 54:3, 212-233, DOI: 10.1080/00981389.2014.999979 To link to this article: http://dx.doi.org/10.1080/00981389.2014.999979
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
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Social Work in Health Care, 54:212–233, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2014.999979
Development of the Emergency Medical Services Role Identity Scale (EMS-RIS) ELIZABETH A. DONNELLY, PhD, LICSW, MPH, NREMT School of Social Work, University of Windsor, Windsor, Ontario, Canada
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DARCY SIEBERT, PhD and CARL SIEBERT, PhD, MBA School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
This article describes the development and validation of the theoretically grounded Emergency Medical Services Role Identity Scale (EMS-RIS), which measures four domains of EMS role identity. The EMS-RIS was developed using a mixed methods approach. Key informants informed item development and the scale was validated using a representative probability sample of EMS personnel. Factor analyses revealed a conceptually consistent, four-factor solution with sound psychometric properties as well as evidence of convergent and discriminant validities. Social workers work with EMS professionals in crisis settings and as their counselors when they are distressed. The EMS-RIS provides useful information for the assessment of and intervention with distressed EMS professionals, as well as how role identity may influence occupational stress. KEYWORDS emergency medical services, paramedical personnel, exploratory factor analysis, role identity
INTRODUCTION The wailing of ambulance sirens is a commonplace occurrence. Although ambulances are a familiar sight, very little is known about the personnel who respond to the ill and injured. Who are these responders? What stressors do Received July 4, 2014; accepted December 15, 2014. Address correspondence to Elizabeth A. Donnelly, PhD, LICSW, MPH, NREMT, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON N9B 3P4, Canada. E-mail: [email protected] 212
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they face? What issues impede their practice? Because the quality of care is paramount to patients facing a critical illness or injury, comprehensive research is necessary so that supervisors and helping professionals (e.g., social workers) can know how to best support these emergency medical services (EMS) responders when they experience their own distress or other barriers to the provision of excellent care. We do know that responders face a multitude of threats to their safety. These risks may include direct threats to the safety of the responder (e.g., assault, back injury, car accident, exposure to blood borne pathogens), as well as the secondary exposure to the injury or illness of their patients (e.g., the death of a child, a mass casualty incident, responding friends or family) (Alexander & Klein, 2001; Becker, Zaloshnja, Levick, Li, & Miller, 2003; Boal, Hales, & Ross, 2005; Boyle, Koritsas, Coles, & Stanley, 2007; Brough, 2005; Sterud, Ekeberg, & Hem, 2006). In addition to direct and indirect threats to safety, responders face chronic work stresses, including long work hours, inadequate pay, sleep deprivation, and conflict with administration and colleagues (Beaton, Murphy, & Pike, 1996; Nirel, Goldwag, Feigenberg, Abadi, & Halpern, 2008; Patterson, et al., 2011; van der Ploeg & Kleber, 2003; Young & Cooper, 1997). The exposure to these work related stresses places EMS responders at a high risk of developing stress related disorders, including posttraumatic stress disorder (Berger et al., 2012; Clohessy & Ehlers, 1999; Donnelly, 2012; Regehr, Goldberg, & Hughes, 2002; Weiss, Marmar, Metzler, & Ronfeldt, 1995). They are also at risk for anxiety and depression (Bentley, Crawford, Wilkins, Fernandez, & Studnek, 2013; Mock, Wrenn, Wright, Eustis, & Slovis, 1999; Roldán, Salazar, Garrido, & Ramos, 2013) and serious suicidal ideation (Sterud, Hem, Lau, & Ekeberg, 2008). Work-related stress in the emergency medical services has also been tied to employee turnover and absenteeism (Blay & Chapman, 2011; Chapman, Blau, Pred, & Lopez, 2009) and negative impacts on the responder’s family system (Regehr, 2005; Roth & Moore, 2009). Research into other crisis responders (e.g., law enforcement, fire services) has tied work-related stress to burnout (Alexander, 1999; Malach-Pines & Keinan, 2006; Martinussen, Richardsen, & Burke, 2007), alcohol misuse (Al-Humaid, el-Guebaly, & Lussier, 2007; Ballenger, et al., 2011; Murphy, Beaton, Pike, & Johnson, 1999; Obst, Davey, & Sheehan, 2001), physical illness (Anderson, Litzenberger, & Plecas, 2002; Kales, Soteriades, Christophi, & Christiani, 2007; Tang & Hammontree, 1992), and suicidal ideation (Savia, 2008; Violanti, 2004). A useful way to begin the investigation into these professionals is to identify who they are, what brings them to the profession, and what causes them to stay, despite all the stressors. Recent research suggests that examining role identity is a good first step, as it has been found to be related to stress, burnout, and other health indicators (e.g., Burke, 1991; Siebert & Siebert, 2007; Thoits, 1991, 1999). Role identity has been successfuly
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measured in other helping populations, including in social workers with the Caregiver Role Identity Scale (Siebert & Siebert, 2005); a scale validated using both exploratory and confirmatory factor analyses. Similar to the research about social workers, the information encompassed in role identity may be the best starting point for understanding and intervening with stressed, overwhelmed emergency responders. Role identity theory describes a process by which individuals develop identity through interaction with their environment (McCall & Simmons, 1978). When individuals occupy social roles (e.g., parent, spouse, lawyer, or EMS responder) and identify with them, they develop a role identity. The development of a role identity serves a very utilitarian purpose. Individuals develop idealized expectations about a role based on general knowledge about the role occupied by other individuals they encounter (McCall & Simmons, 1978). Individuals then legitimate their identity by behaving in a way they believe is appropriate for the role they hold and by modifying their conduct based on the feedback received from others about themselves in the role (McCall & Simmons, 1978). Role identity can be powerful, acting as both the primary source of plans of action as well as a filter through which individuals interpret events and interactions with others (McCall & Simmons, 1978). Individuals hold multiple roles; some roles are more salient than others. If a role is highly salient to an individual, events that enhance that role may contribute to a sense of well being. Conversely, events that threaten that role may predict psychological distress (Thoits, 1991). The nature of EMS work lends itself to a high level of commitment from responders, increasing the chance of a high level of salience in the role of EMS responder. Factors that may make this identity more salient include the fact that responders often work long hours (e.g., Studnek & Fernandez, 2008), responders are routinely placed at risk of violence as part of their work (Bigham et al., 2014), and may be called on to make life or death decisions. Given the significance that a the role of EMS responder may hold for an individual, threats to that identity may place them at risk for distress. For example, a responder may feel that they are “only doing their job,” but be identified and lauded as heroes by the press after a large-scale response or be blamed for the death of an infant by distraught parents in circumstances beyond the responder’s control. In both cases, the dissonance in perception of the responder’s success in fulfilling their role may cause an increase in level of stress and possibility for a stress reaction. The impact of role dissonance may have consequences beyond the individual responder. Anecdotal evidence indicates that responders who are unhappy with their role may negatively impact their patients. For example, responders who are stressed or burned out may potentially take out their frustrations on their patients by being neglectful, rude, or abusive. Conversely, those who are satisfied with their role may be more likely to react with compassion and sensitivity to patient complaints. Given the
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potential ramifications of how EMS personnel feel about their role as responders, it becomes important to explore how responders may conceptualize that role. Thus, the purpose of this study is to describe the development and validation of a psychometrically sound measure of role identity for emergency medical responders. We utilized a mixed methods approach, using qualitative methods to develop the items and quantitative methods to test and validate them.
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Role Identity in the Emergency Medical Services Role identity theory recognizes that identity is not homogenous. Thus, the EMS responder’s role identity is not conceptualized as a homogeneous identity. All EMS responders may identify as “emergency medical technician (EMT)” or “paramedic,” but individuals may identify with different aspects of the identity. Even though the impact of role identity is established in the literature, no extant efforts have explored EMS role identity. Therefore, it was necessary to begin the measure development with a qualitative exploration of EMS role identity. As the existing literature has little to say in this area, we drew upon personal experience as well as a series of interviews with five key informants to explore the possible domains of EMS identity. The first author holds certification as an emergency medical technician has been actively involved in EMS for over 15 years. This engagement in EMS has taken on multiple forms, including 911 emergency response, basic life support ambulance work, and event first aid services. Key informants were individuals previously known to the authors who were primarily employed as EMS workers. Informants worked at both the emergency medical technician and paramedic levels, in fire-based and third-service EMS services, and were actively involved in front-line patient care. Interviews began by asking key informants, “Why are you in EMS?” and “What do you like best about being in EMS?” followed by probing questions that varied according to the participants’ responses. After the interviews were completed, all the responses were reviewed, coded, and themes identified. After this analysis, four domains of EMS role identity emerged. These domains are caregiving, thrill seeking, capacity, and duty. These identities are not conceptualized as mutually exclusive, nor can they comprehensively describe an overall EMS role identity. However, the key informants most frequently described these four domains. The first domain that might be influential in a responder’s sense of role is that of caregiving. The caregiving domain reflects Simon’s (1997) identification of helping others, making a contribution, being productive and belonging as important to the development of occupational role identity.
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As a professional caregiver, the individual responder values his or her role as a service provider and draws a sense of purpose from interaction with patients. Brad W, paramedic, expressed this sentiment as follows:
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I enjoy the intimate position of helping someone with very little inhibitions present. People are their most honest with me, and feel they can tell me everything. For me, it is not the ‘lifesaving,’ whatever the hell that is; it is the little things. . . . It simply comes down to me being there for a person in need. (personal communication, September 24, 2007)
The second domain that emerged in the study is that of thrill seeking, wherein the individuals are in EMS because of the potentially dramatic and exciting nature of scenes to which they may respond. The thrill-seeker enjoys the high visibility of the profession and is invigorated by situations in which someone may be critically ill or injured. Brian J., EMT, articulated this role as follows: There’s nothing cooler in this world than a Ford F350 Ambulance driving code three (driving with lights and sirens) the wrong way down a two way street as people look at you in awe is really cool. I am definitely an adrenaline junkie . . . . I get a GSW (gun shot wound) or a good MVA (motor vehicle accident), and I’m psyched. (personal communication, September 19, 2007)
The third EMT identity is that of capacity. An oft-repeated sentiment among the key informants was the sense that “I do this work because I am capable of it and few others are.” The capacity identity is one in which individuals feel that they have the capacity to act in situations in which others could or would not intervene and to cope with the aftermath. This domain reflects the importance to occupational identity of meeting challenges and attaining goals (Simon, 1997). Again, Brian J., EMT: There are a lot of people in this world that don’t have the temperament or the stomach or quite frankly the brain to do what we do. The common reality that at least once a month, or at least it’s been this way for me, you’re going to have someone die on you, and you get this job. I do it because I’m good at it, it’s been in my family for a long time and there aren’t many people who can do it, and there are even fewer who can do it as or better than I can. (personal communication, September 19, 2007)
Annie F., paramedic, articulates the same identity differently, as follows: When you decide to acquire a skill that puts you to a duty to act, you basically have to act every time something bad happens. When you do,
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you open yourself up to a great deal of emotional risk. What if you do the wrong thing? What if you do everything right and the outcome is still tragic? When you take on this particular skill set, you give up the luxury of doing nothing because you’re afraid. (personal communication, September 24, 2007)
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The fourth domain identified for the emergency responder involves duty. This duty reflects a sense of obligation to the profession and to the community as well as a commitment to public service, and it is consistent with the importance of responsibility and stability to occupational role identity (Simon, 1997). In the words of Andy R., paramedic: I have little respect for medics who think that they are wonderful angelic lifesavers. I respect medics who are fun to work with and treat their patients like real people. Most of my favorite partners come to work every day because this is what they do . . . they know that they need to work, They know that they need to do their jobs, even when they don’t feel like it. Duty is really important to good paramedics. (personal communication, September 24, 2007)
Scale Development After the qualitative data were analyzed using a deductive approach to thematic analysis to identify the domains of the EMS Role Identity Scale (EMS-RIS), we used the data and the literature to generate 71 items across the four identified domains of caregiving, thrill seeking, capacity, and duty. Theory suggests that role identity develops as a result of the individual’s beliefs about himself/herself in the role, and the beliefs that develop as a result of interactions with others about the role. Thus the items were constructed accordingly, so that some reflected the individual’s sense of their role (e.g., I feel that . . .) as well as their perception of others’ beliefs (e.g., Others tell me that I . . .). In some cases, items directly quoted the language used by key informants in the qualitative data collection. Feedback was solicited from scholarly peers, who evaluated syntax, conceptual cohesion, and structural concerns that may lead to bias. After scholarly review, the items were reviewed by an expert panel (n = 8) of three EMTs and five paramedics, five men and three women. Panelists had between 1 and 19 years of experience in EMS, with a mean of 7 years of experience (SD = 5.53) and were geographically diverse; panelists were located in California, New York, Arizona, Florida, and Minnesota. Panelists rated items according to how closely they felt each item fit with the sub-scale definition. Response options for their evaluation utilized a 7-point Likert-like format, ranging from 1 (not close) to 7 (very close). Items with a mean score under five were judged to be less precisely descriptive of the subscale definition and were eliminated. The
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expert panel reduced the number of items to 54; the caregiving sub-scale retained 18 items, and the thrill seeking, capacity, and duty sub-scales each retained 12 items. After the expert panel evaluated the EMS-RIS, an online survey was constructed using SNAP survey software v.9. A probability sample of EMTs and paramedics (n = 1,000) was provided by the National Registry of EMTs (NREMT), a not-for-profit, nongovernmental agency that administers qualifying examinations and registers EMS providers in the United States. The NREMT had begun collecting e-mail addresses systematically in 2007, so the probability sample was drawn from those who had passed the initial EMT or paramedic exam sometime in 2007 or 2008. All respondents were certified as EMTs or paramedics and therefore were qualified to deliver patient care. The sample participants were contacted following the guidelines suggested by Dillman (2000). They first received an e-mail introducing the study, and then several days later they received the first of four e-mail invitations to complete the survey. E-mailed invitations were sent every 10–12 days, and participants who completed the survey did not receive subsequent reminder e-mails. Participants were asked to identify how true each EMS-RIS item was for them, using a 7-point Likert-like format, ranging from 1 (entirely untrue) to 7 (entirely true). The questionnaire also included demographic questions and several previously validated measures to examine validity. Of the 1,000 individuals identified for participation, 75 had non-functional e-mail addresses and three individuals requested to be removed from the mailing list. At the end of data collection, 207 individuals had responded, so the overall response rate was 22% (207/922), which is considered an acceptable sample size for factor analysis (Comrey, 1988)
Measures In addition to the EMS-RIS scale, several other scales were included to test for evidence of convergent construct validity. Specifically, the four sub-scales of the EMS-RIS were matched with previously validated measures for other constructs that were considered theoretically similar to the EMS-RIS sub-scales. Convergent validity is supported if a strong correlation is found between the EMS-RIS sub-scale and the previously validated measure (DeVellis, 2003). CAREGIVING The caregiving sub-scale proposed in the EMS-RIS is similar to one already in the literature: the caregiver role identity. The caregiver role identity has been defined as “framed by the notion of giving rather than needing to receive help, having pride in their intellectual ability to problem solve, and being in a position of power when dealing with their clients” (Siebert & Siebert, 2007, p. 50). The hypothesis for convergent validity evidence between these
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two constructs is as follows: if there is a high level of identification on the EMS role identity caregiver subscale, there will be a correspondingly high endorsement of the caregiver role identity. This hypothesis was tested using the Caregiver Role Identity Scale (Siebert & Siebert, 2005), an eight-item scale developed for use with social workers that assesses both the individual’s sense of self (role performance) and other’s sense of them (role support) as a caregiver. This scale has demonstrated acceptable reliability (α = .78).
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THRILL SEEKING The elements of this sub-scale emphasize the individual seeking the excitement and stimulation of dramatic situations, reflecting the characteristics found in the construct of sensation seeking. Sensation seeking has been defined as “the need for varied, novel, and complex sensations and experiences and the willingness to take physical and social risks for the sake of such experiences” (Zuckerman, 1979, p. 10). Although the EMS-RIS thrill seeking sub-scale is occupationally specific to EMS, the sensation-seeking construct emphasizes similar themes, but generally. We hypothesized that the individual scoring highly on the thrill-seeking items will also score highly in sensation seeking behaviors. Thus, we included the Brief Sensation Seeking Scale (BSSS), an eight-item scale that measures four dimensions of sensation seeking— experience seeking, boredom susceptibility, thrill and adventure seeking, and disinhibition. This scale has previously demonstrated reliability of α = .74 (Hoyle, Stephenson, Palmgreen, Pugzles Lorch, & Donohew, 2002). CAPACITY The construct identified as most similar to the capacity sub-scale is that of general self-efficacy. The construct of general self-efficacy “has been conceptualized as a relatively stable generalized belief that an individual can marshal the resources needed to deal with the challenges that he or she experiences” (Scherbaum, Cohen-Charash, & Kern, 2006, p. 1049). Although this definition of efficacy is more global than that of occupational capacity in the EMS role identity, it taps into the same sense of confidence in ability in a variety of situations. This definition of general self-efficacy emphasizes its stability as a personality trait, so it is reasonable to hypothesize that if someone is generally efficacious, that person is more likely to have high selfefficacy in the professional environment. To test this, the New General Self Efficacy Scale (NGSE), a one-dimensional, eight-item scale that has demonstrated good past reliability (α = .85–.88) (Chen, Gully, & Eden, 2001) was used.
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DUTY This specific sense of occupation related duty identified in the EMS-RIS reflects a more general sense of duty. Duty is defined as “something that one is expected or required to do by moral or legal obligation” (Dictionary.com, 2010). While the construct of moral obligation is perhaps closer to the EMS sub-scale of duty, no appropriate measures are extant in the literature. Therefore, it is necessary to turn to the legal obligation element of the definition of duty to find an appropriate corollary for measurement of convergent validity. The hypothesis is that if an individual has a strong sense of duty professionally, they will have a strong sense of duty generally, including duty to obey the law. We hypothesize that the duty sub-scale of the EMSRIS will positively related to commitment to obedience of the law. To assess the degree to which individuals are committed to obeying the law, the fiveitem Obedience to the Law scale was used. This scale has a previously demonstrated reliability of α = 0.90 (Lee & Ottati, 2002). Of the previously validated measures, the caregiver role identity scale, the brief sensation seeking scale, and the new general self-efficacy scale were initially validated with a 5-point Likert format. However, to remain consistent with the EMS-RIS, to keep the response options consistent for respondents, and with permission of the authors, the response options were changed to a 7-point Likert, ranging from 1 (strongly disagree) to 7 (strongly agree). Despite the change in response options, all scales retained acceptable reliability (Cronbach’s alpha) scores.
Demographics In addition to the measures for examining convergent validity, participants were asked to report their age, gender, level of certification (EMT vs. paramedic), whether they worked in an urban, suburban, or rural area, and how long they had been working in EMS. In addition to their descriptive value, several of these variables were hypothesized to be indicators of discriminant validity. If no significant relationship was found between these indicators and specified EMS-RIS constructs, evidence of discriminant validity would be supported.
ANALYSIS When data collection was complete, analyses began using Statistical Package for Social Sciences (SPSS) 21.0. First, the data were assessed for missingness, which was not found to be problematic within this sample as 98% of the sample (n = 203) had completed at least 85% of the survey (Hertel, 1976). Item non-response was not problematic, as all items had at least a 94%
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response rate. Statistical assumptions for analysis were met insofar as the data were linearly related and moderately correlated. The data were examined for inter-item correlations using the multiple group method (Nunnally & Bernstein, 1994; Springer, Abell, & Nugent, 2002). Items correlating above .75 with any other item were considered to have too much overlap with the other item(s) (i.e., were redundant) and were removed. Items not correlating with any item above .3 were removed because they were not contributing to the latent construct. Thirty-nine items were retained for factor analysis Factor analysis began with an unrotated principal components analysis (PCA). An examination of the Scree plot and factor matrix revealed four plausible factors. The data were then run through a series of principal axis factor analyses with an oblique (direct oblimin) rotation that allowed the factors to correlate, as theoretically hypothesized. In each analysis run, the items were examined for statistical and theoretical appropriateness, removing one inappropriate item at each iteration until the final solution was found. In the final iterations, the factors were constrained to four, as the initial analyses suggested. Internal consistency reliability was examined by calculating Cronbach alpha for each subscale. Next, the mean scores for the EMS-RIS subscales and the previously validated measures were calculated. To assess for convergent validity on the EMS-RIS, bivariate correlations were examined between the mean scores of the subscales of the EMS-RIS and the previously validated measures. To test for discriminant validity, the sub-scales of the EMS-RIS were tested against the variables gender and level of training using t-tests, and urbanicity of service area using ANOVA. We hypothesized that specific role identities would not be related to these demographic characteristics and that this might provide some limited support for discriminant validity.
RESULTS Sample Characteristics Of the 207 respondents, 67% were male (n = 138) and 33% were female (n = 69). Fifty-two percent of respondents were paramedics (n = 108) and 46% were EMTs (n = 96) with 3% not reporting their level of training. The ages of respondents ranged from 18–56, with a mean age of 30.78 (SD 9.11). Respondents were fairly equally distributed in types of service area, with 30% reporting that they worked in an urban area (n = 62), 30% working in a suburban area (n = 63) and 36% working in a rural area (n = 73). Four percent did not report the urbanicity of their service area. Finally, respondents reported a wide range of time in EMS, ranging from 1 month to over 30 years. Mean time in service was 5.5 years (SD 6.27). This variable was skewed due to the nature of the sampling frame; 30% of respondents reported less than one year of service, and these were primarily EMTs (n = 54).
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The demographic characteristics of this sample vary slightly from the National Registry of EMTs demographic data, insofar as this sample is slightly younger. According to the NREMT, the mean age of EMTs is 36.5 years and 35.1 years for paramedics (National Registry of Emergency Medical Technicians [NREMT], 2006), whereas in our sample, EMTs had a mean age of 29.8 years and paramedics had a mean age of 31.5 years. The gender distribution appears to be reasonably close to the overall population, where 65% of EMTs are male, and 73% of paramedics are male (NREMT, 2006).
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EMS-RIS Reliability Principal axis factoring with an oblique rotation revealed a four factor, 26item solution (KMO = .864; Bartlett’s Test χ2 = 2209.94, df = 325, p
Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
Development of the Emergency Medical Services Role Identity Scale (EMS-RIS) a
Elizabeth A. Donnelly PhD, LICSW, MPH, NREMT , Darcy Siebert PhD & Carl Siebert PhD, MBA
b
b
a
School of Social Work, University of Windsor, Windsor, Ontario, Canada b
School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA Published online: 11 Mar 2015.
Click for updates To cite this article: Elizabeth A. Donnelly PhD, LICSW, MPH, NREMT, Darcy Siebert PhD & Carl Siebert PhD, MBA (2015) Development of the Emergency Medical Services Role Identity Scale (EMS-RIS), Social Work in Health Care, 54:3, 212-233, DOI: 10.1080/00981389.2014.999979 To link to this article: http://dx.doi.org/10.1080/00981389.2014.999979
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [New York University] at 15:02 06 June 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Social Work in Health Care, 54:212–233, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2014.999979
Development of the Emergency Medical Services Role Identity Scale (EMS-RIS) ELIZABETH A. DONNELLY, PhD, LICSW, MPH, NREMT School of Social Work, University of Windsor, Windsor, Ontario, Canada
Downloaded by [New York University] at 15:02 06 June 2015
DARCY SIEBERT, PhD and CARL SIEBERT, PhD, MBA School of Social Work, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
This article describes the development and validation of the theoretically grounded Emergency Medical Services Role Identity Scale (EMS-RIS), which measures four domains of EMS role identity. The EMS-RIS was developed using a mixed methods approach. Key informants informed item development and the scale was validated using a representative probability sample of EMS personnel. Factor analyses revealed a conceptually consistent, four-factor solution with sound psychometric properties as well as evidence of convergent and discriminant validities. Social workers work with EMS professionals in crisis settings and as their counselors when they are distressed. The EMS-RIS provides useful information for the assessment of and intervention with distressed EMS professionals, as well as how role identity may influence occupational stress. KEYWORDS emergency medical services, paramedical personnel, exploratory factor analysis, role identity
INTRODUCTION The wailing of ambulance sirens is a commonplace occurrence. Although ambulances are a familiar sight, very little is known about the personnel who respond to the ill and injured. Who are these responders? What stressors do Received July 4, 2014; accepted December 15, 2014. Address correspondence to Elizabeth A. Donnelly, PhD, LICSW, MPH, NREMT, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON N9B 3P4, Canada. E-mail: [email protected] 212
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they face? What issues impede their practice? Because the quality of care is paramount to patients facing a critical illness or injury, comprehensive research is necessary so that supervisors and helping professionals (e.g., social workers) can know how to best support these emergency medical services (EMS) responders when they experience their own distress or other barriers to the provision of excellent care. We do know that responders face a multitude of threats to their safety. These risks may include direct threats to the safety of the responder (e.g., assault, back injury, car accident, exposure to blood borne pathogens), as well as the secondary exposure to the injury or illness of their patients (e.g., the death of a child, a mass casualty incident, responding friends or family) (Alexander & Klein, 2001; Becker, Zaloshnja, Levick, Li, & Miller, 2003; Boal, Hales, & Ross, 2005; Boyle, Koritsas, Coles, & Stanley, 2007; Brough, 2005; Sterud, Ekeberg, & Hem, 2006). In addition to direct and indirect threats to safety, responders face chronic work stresses, including long work hours, inadequate pay, sleep deprivation, and conflict with administration and colleagues (Beaton, Murphy, & Pike, 1996; Nirel, Goldwag, Feigenberg, Abadi, & Halpern, 2008; Patterson, et al., 2011; van der Ploeg & Kleber, 2003; Young & Cooper, 1997). The exposure to these work related stresses places EMS responders at a high risk of developing stress related disorders, including posttraumatic stress disorder (Berger et al., 2012; Clohessy & Ehlers, 1999; Donnelly, 2012; Regehr, Goldberg, & Hughes, 2002; Weiss, Marmar, Metzler, & Ronfeldt, 1995). They are also at risk for anxiety and depression (Bentley, Crawford, Wilkins, Fernandez, & Studnek, 2013; Mock, Wrenn, Wright, Eustis, & Slovis, 1999; Roldán, Salazar, Garrido, & Ramos, 2013) and serious suicidal ideation (Sterud, Hem, Lau, & Ekeberg, 2008). Work-related stress in the emergency medical services has also been tied to employee turnover and absenteeism (Blay & Chapman, 2011; Chapman, Blau, Pred, & Lopez, 2009) and negative impacts on the responder’s family system (Regehr, 2005; Roth & Moore, 2009). Research into other crisis responders (e.g., law enforcement, fire services) has tied work-related stress to burnout (Alexander, 1999; Malach-Pines & Keinan, 2006; Martinussen, Richardsen, & Burke, 2007), alcohol misuse (Al-Humaid, el-Guebaly, & Lussier, 2007; Ballenger, et al., 2011; Murphy, Beaton, Pike, & Johnson, 1999; Obst, Davey, & Sheehan, 2001), physical illness (Anderson, Litzenberger, & Plecas, 2002; Kales, Soteriades, Christophi, & Christiani, 2007; Tang & Hammontree, 1992), and suicidal ideation (Savia, 2008; Violanti, 2004). A useful way to begin the investigation into these professionals is to identify who they are, what brings them to the profession, and what causes them to stay, despite all the stressors. Recent research suggests that examining role identity is a good first step, as it has been found to be related to stress, burnout, and other health indicators (e.g., Burke, 1991; Siebert & Siebert, 2007; Thoits, 1991, 1999). Role identity has been successfuly
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measured in other helping populations, including in social workers with the Caregiver Role Identity Scale (Siebert & Siebert, 2005); a scale validated using both exploratory and confirmatory factor analyses. Similar to the research about social workers, the information encompassed in role identity may be the best starting point for understanding and intervening with stressed, overwhelmed emergency responders. Role identity theory describes a process by which individuals develop identity through interaction with their environment (McCall & Simmons, 1978). When individuals occupy social roles (e.g., parent, spouse, lawyer, or EMS responder) and identify with them, they develop a role identity. The development of a role identity serves a very utilitarian purpose. Individuals develop idealized expectations about a role based on general knowledge about the role occupied by other individuals they encounter (McCall & Simmons, 1978). Individuals then legitimate their identity by behaving in a way they believe is appropriate for the role they hold and by modifying their conduct based on the feedback received from others about themselves in the role (McCall & Simmons, 1978). Role identity can be powerful, acting as both the primary source of plans of action as well as a filter through which individuals interpret events and interactions with others (McCall & Simmons, 1978). Individuals hold multiple roles; some roles are more salient than others. If a role is highly salient to an individual, events that enhance that role may contribute to a sense of well being. Conversely, events that threaten that role may predict psychological distress (Thoits, 1991). The nature of EMS work lends itself to a high level of commitment from responders, increasing the chance of a high level of salience in the role of EMS responder. Factors that may make this identity more salient include the fact that responders often work long hours (e.g., Studnek & Fernandez, 2008), responders are routinely placed at risk of violence as part of their work (Bigham et al., 2014), and may be called on to make life or death decisions. Given the significance that a the role of EMS responder may hold for an individual, threats to that identity may place them at risk for distress. For example, a responder may feel that they are “only doing their job,” but be identified and lauded as heroes by the press after a large-scale response or be blamed for the death of an infant by distraught parents in circumstances beyond the responder’s control. In both cases, the dissonance in perception of the responder’s success in fulfilling their role may cause an increase in level of stress and possibility for a stress reaction. The impact of role dissonance may have consequences beyond the individual responder. Anecdotal evidence indicates that responders who are unhappy with their role may negatively impact their patients. For example, responders who are stressed or burned out may potentially take out their frustrations on their patients by being neglectful, rude, or abusive. Conversely, those who are satisfied with their role may be more likely to react with compassion and sensitivity to patient complaints. Given the
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potential ramifications of how EMS personnel feel about their role as responders, it becomes important to explore how responders may conceptualize that role. Thus, the purpose of this study is to describe the development and validation of a psychometrically sound measure of role identity for emergency medical responders. We utilized a mixed methods approach, using qualitative methods to develop the items and quantitative methods to test and validate them.
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Role Identity in the Emergency Medical Services Role identity theory recognizes that identity is not homogenous. Thus, the EMS responder’s role identity is not conceptualized as a homogeneous identity. All EMS responders may identify as “emergency medical technician (EMT)” or “paramedic,” but individuals may identify with different aspects of the identity. Even though the impact of role identity is established in the literature, no extant efforts have explored EMS role identity. Therefore, it was necessary to begin the measure development with a qualitative exploration of EMS role identity. As the existing literature has little to say in this area, we drew upon personal experience as well as a series of interviews with five key informants to explore the possible domains of EMS identity. The first author holds certification as an emergency medical technician has been actively involved in EMS for over 15 years. This engagement in EMS has taken on multiple forms, including 911 emergency response, basic life support ambulance work, and event first aid services. Key informants were individuals previously known to the authors who were primarily employed as EMS workers. Informants worked at both the emergency medical technician and paramedic levels, in fire-based and third-service EMS services, and were actively involved in front-line patient care. Interviews began by asking key informants, “Why are you in EMS?” and “What do you like best about being in EMS?” followed by probing questions that varied according to the participants’ responses. After the interviews were completed, all the responses were reviewed, coded, and themes identified. After this analysis, four domains of EMS role identity emerged. These domains are caregiving, thrill seeking, capacity, and duty. These identities are not conceptualized as mutually exclusive, nor can they comprehensively describe an overall EMS role identity. However, the key informants most frequently described these four domains. The first domain that might be influential in a responder’s sense of role is that of caregiving. The caregiving domain reflects Simon’s (1997) identification of helping others, making a contribution, being productive and belonging as important to the development of occupational role identity.
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As a professional caregiver, the individual responder values his or her role as a service provider and draws a sense of purpose from interaction with patients. Brad W, paramedic, expressed this sentiment as follows:
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I enjoy the intimate position of helping someone with very little inhibitions present. People are their most honest with me, and feel they can tell me everything. For me, it is not the ‘lifesaving,’ whatever the hell that is; it is the little things. . . . It simply comes down to me being there for a person in need. (personal communication, September 24, 2007)
The second domain that emerged in the study is that of thrill seeking, wherein the individuals are in EMS because of the potentially dramatic and exciting nature of scenes to which they may respond. The thrill-seeker enjoys the high visibility of the profession and is invigorated by situations in which someone may be critically ill or injured. Brian J., EMT, articulated this role as follows: There’s nothing cooler in this world than a Ford F350 Ambulance driving code three (driving with lights and sirens) the wrong way down a two way street as people look at you in awe is really cool. I am definitely an adrenaline junkie . . . . I get a GSW (gun shot wound) or a good MVA (motor vehicle accident), and I’m psyched. (personal communication, September 19, 2007)
The third EMT identity is that of capacity. An oft-repeated sentiment among the key informants was the sense that “I do this work because I am capable of it and few others are.” The capacity identity is one in which individuals feel that they have the capacity to act in situations in which others could or would not intervene and to cope with the aftermath. This domain reflects the importance to occupational identity of meeting challenges and attaining goals (Simon, 1997). Again, Brian J., EMT: There are a lot of people in this world that don’t have the temperament or the stomach or quite frankly the brain to do what we do. The common reality that at least once a month, or at least it’s been this way for me, you’re going to have someone die on you, and you get this job. I do it because I’m good at it, it’s been in my family for a long time and there aren’t many people who can do it, and there are even fewer who can do it as or better than I can. (personal communication, September 19, 2007)
Annie F., paramedic, articulates the same identity differently, as follows: When you decide to acquire a skill that puts you to a duty to act, you basically have to act every time something bad happens. When you do,
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you open yourself up to a great deal of emotional risk. What if you do the wrong thing? What if you do everything right and the outcome is still tragic? When you take on this particular skill set, you give up the luxury of doing nothing because you’re afraid. (personal communication, September 24, 2007)
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The fourth domain identified for the emergency responder involves duty. This duty reflects a sense of obligation to the profession and to the community as well as a commitment to public service, and it is consistent with the importance of responsibility and stability to occupational role identity (Simon, 1997). In the words of Andy R., paramedic: I have little respect for medics who think that they are wonderful angelic lifesavers. I respect medics who are fun to work with and treat their patients like real people. Most of my favorite partners come to work every day because this is what they do . . . they know that they need to work, They know that they need to do their jobs, even when they don’t feel like it. Duty is really important to good paramedics. (personal communication, September 24, 2007)
Scale Development After the qualitative data were analyzed using a deductive approach to thematic analysis to identify the domains of the EMS Role Identity Scale (EMS-RIS), we used the data and the literature to generate 71 items across the four identified domains of caregiving, thrill seeking, capacity, and duty. Theory suggests that role identity develops as a result of the individual’s beliefs about himself/herself in the role, and the beliefs that develop as a result of interactions with others about the role. Thus the items were constructed accordingly, so that some reflected the individual’s sense of their role (e.g., I feel that . . .) as well as their perception of others’ beliefs (e.g., Others tell me that I . . .). In some cases, items directly quoted the language used by key informants in the qualitative data collection. Feedback was solicited from scholarly peers, who evaluated syntax, conceptual cohesion, and structural concerns that may lead to bias. After scholarly review, the items were reviewed by an expert panel (n = 8) of three EMTs and five paramedics, five men and three women. Panelists had between 1 and 19 years of experience in EMS, with a mean of 7 years of experience (SD = 5.53) and were geographically diverse; panelists were located in California, New York, Arizona, Florida, and Minnesota. Panelists rated items according to how closely they felt each item fit with the sub-scale definition. Response options for their evaluation utilized a 7-point Likert-like format, ranging from 1 (not close) to 7 (very close). Items with a mean score under five were judged to be less precisely descriptive of the subscale definition and were eliminated. The
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expert panel reduced the number of items to 54; the caregiving sub-scale retained 18 items, and the thrill seeking, capacity, and duty sub-scales each retained 12 items. After the expert panel evaluated the EMS-RIS, an online survey was constructed using SNAP survey software v.9. A probability sample of EMTs and paramedics (n = 1,000) was provided by the National Registry of EMTs (NREMT), a not-for-profit, nongovernmental agency that administers qualifying examinations and registers EMS providers in the United States. The NREMT had begun collecting e-mail addresses systematically in 2007, so the probability sample was drawn from those who had passed the initial EMT or paramedic exam sometime in 2007 or 2008. All respondents were certified as EMTs or paramedics and therefore were qualified to deliver patient care. The sample participants were contacted following the guidelines suggested by Dillman (2000). They first received an e-mail introducing the study, and then several days later they received the first of four e-mail invitations to complete the survey. E-mailed invitations were sent every 10–12 days, and participants who completed the survey did not receive subsequent reminder e-mails. Participants were asked to identify how true each EMS-RIS item was for them, using a 7-point Likert-like format, ranging from 1 (entirely untrue) to 7 (entirely true). The questionnaire also included demographic questions and several previously validated measures to examine validity. Of the 1,000 individuals identified for participation, 75 had non-functional e-mail addresses and three individuals requested to be removed from the mailing list. At the end of data collection, 207 individuals had responded, so the overall response rate was 22% (207/922), which is considered an acceptable sample size for factor analysis (Comrey, 1988)
Measures In addition to the EMS-RIS scale, several other scales were included to test for evidence of convergent construct validity. Specifically, the four sub-scales of the EMS-RIS were matched with previously validated measures for other constructs that were considered theoretically similar to the EMS-RIS sub-scales. Convergent validity is supported if a strong correlation is found between the EMS-RIS sub-scale and the previously validated measure (DeVellis, 2003). CAREGIVING The caregiving sub-scale proposed in the EMS-RIS is similar to one already in the literature: the caregiver role identity. The caregiver role identity has been defined as “framed by the notion of giving rather than needing to receive help, having pride in their intellectual ability to problem solve, and being in a position of power when dealing with their clients” (Siebert & Siebert, 2007, p. 50). The hypothesis for convergent validity evidence between these
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two constructs is as follows: if there is a high level of identification on the EMS role identity caregiver subscale, there will be a correspondingly high endorsement of the caregiver role identity. This hypothesis was tested using the Caregiver Role Identity Scale (Siebert & Siebert, 2005), an eight-item scale developed for use with social workers that assesses both the individual’s sense of self (role performance) and other’s sense of them (role support) as a caregiver. This scale has demonstrated acceptable reliability (α = .78).
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THRILL SEEKING The elements of this sub-scale emphasize the individual seeking the excitement and stimulation of dramatic situations, reflecting the characteristics found in the construct of sensation seeking. Sensation seeking has been defined as “the need for varied, novel, and complex sensations and experiences and the willingness to take physical and social risks for the sake of such experiences” (Zuckerman, 1979, p. 10). Although the EMS-RIS thrill seeking sub-scale is occupationally specific to EMS, the sensation-seeking construct emphasizes similar themes, but generally. We hypothesized that the individual scoring highly on the thrill-seeking items will also score highly in sensation seeking behaviors. Thus, we included the Brief Sensation Seeking Scale (BSSS), an eight-item scale that measures four dimensions of sensation seeking— experience seeking, boredom susceptibility, thrill and adventure seeking, and disinhibition. This scale has previously demonstrated reliability of α = .74 (Hoyle, Stephenson, Palmgreen, Pugzles Lorch, & Donohew, 2002). CAPACITY The construct identified as most similar to the capacity sub-scale is that of general self-efficacy. The construct of general self-efficacy “has been conceptualized as a relatively stable generalized belief that an individual can marshal the resources needed to deal with the challenges that he or she experiences” (Scherbaum, Cohen-Charash, & Kern, 2006, p. 1049). Although this definition of efficacy is more global than that of occupational capacity in the EMS role identity, it taps into the same sense of confidence in ability in a variety of situations. This definition of general self-efficacy emphasizes its stability as a personality trait, so it is reasonable to hypothesize that if someone is generally efficacious, that person is more likely to have high selfefficacy in the professional environment. To test this, the New General Self Efficacy Scale (NGSE), a one-dimensional, eight-item scale that has demonstrated good past reliability (α = .85–.88) (Chen, Gully, & Eden, 2001) was used.
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DUTY This specific sense of occupation related duty identified in the EMS-RIS reflects a more general sense of duty. Duty is defined as “something that one is expected or required to do by moral or legal obligation” (Dictionary.com, 2010). While the construct of moral obligation is perhaps closer to the EMS sub-scale of duty, no appropriate measures are extant in the literature. Therefore, it is necessary to turn to the legal obligation element of the definition of duty to find an appropriate corollary for measurement of convergent validity. The hypothesis is that if an individual has a strong sense of duty professionally, they will have a strong sense of duty generally, including duty to obey the law. We hypothesize that the duty sub-scale of the EMSRIS will positively related to commitment to obedience of the law. To assess the degree to which individuals are committed to obeying the law, the fiveitem Obedience to the Law scale was used. This scale has a previously demonstrated reliability of α = 0.90 (Lee & Ottati, 2002). Of the previously validated measures, the caregiver role identity scale, the brief sensation seeking scale, and the new general self-efficacy scale were initially validated with a 5-point Likert format. However, to remain consistent with the EMS-RIS, to keep the response options consistent for respondents, and with permission of the authors, the response options were changed to a 7-point Likert, ranging from 1 (strongly disagree) to 7 (strongly agree). Despite the change in response options, all scales retained acceptable reliability (Cronbach’s alpha) scores.
Demographics In addition to the measures for examining convergent validity, participants were asked to report their age, gender, level of certification (EMT vs. paramedic), whether they worked in an urban, suburban, or rural area, and how long they had been working in EMS. In addition to their descriptive value, several of these variables were hypothesized to be indicators of discriminant validity. If no significant relationship was found between these indicators and specified EMS-RIS constructs, evidence of discriminant validity would be supported.
ANALYSIS When data collection was complete, analyses began using Statistical Package for Social Sciences (SPSS) 21.0. First, the data were assessed for missingness, which was not found to be problematic within this sample as 98% of the sample (n = 203) had completed at least 85% of the survey (Hertel, 1976). Item non-response was not problematic, as all items had at least a 94%
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response rate. Statistical assumptions for analysis were met insofar as the data were linearly related and moderately correlated. The data were examined for inter-item correlations using the multiple group method (Nunnally & Bernstein, 1994; Springer, Abell, & Nugent, 2002). Items correlating above .75 with any other item were considered to have too much overlap with the other item(s) (i.e., were redundant) and were removed. Items not correlating with any item above .3 were removed because they were not contributing to the latent construct. Thirty-nine items were retained for factor analysis Factor analysis began with an unrotated principal components analysis (PCA). An examination of the Scree plot and factor matrix revealed four plausible factors. The data were then run through a series of principal axis factor analyses with an oblique (direct oblimin) rotation that allowed the factors to correlate, as theoretically hypothesized. In each analysis run, the items were examined for statistical and theoretical appropriateness, removing one inappropriate item at each iteration until the final solution was found. In the final iterations, the factors were constrained to four, as the initial analyses suggested. Internal consistency reliability was examined by calculating Cronbach alpha for each subscale. Next, the mean scores for the EMS-RIS subscales and the previously validated measures were calculated. To assess for convergent validity on the EMS-RIS, bivariate correlations were examined between the mean scores of the subscales of the EMS-RIS and the previously validated measures. To test for discriminant validity, the sub-scales of the EMS-RIS were tested against the variables gender and level of training using t-tests, and urbanicity of service area using ANOVA. We hypothesized that specific role identities would not be related to these demographic characteristics and that this might provide some limited support for discriminant validity.
RESULTS Sample Characteristics Of the 207 respondents, 67% were male (n = 138) and 33% were female (n = 69). Fifty-two percent of respondents were paramedics (n = 108) and 46% were EMTs (n = 96) with 3% not reporting their level of training. The ages of respondents ranged from 18–56, with a mean age of 30.78 (SD 9.11). Respondents were fairly equally distributed in types of service area, with 30% reporting that they worked in an urban area (n = 62), 30% working in a suburban area (n = 63) and 36% working in a rural area (n = 73). Four percent did not report the urbanicity of their service area. Finally, respondents reported a wide range of time in EMS, ranging from 1 month to over 30 years. Mean time in service was 5.5 years (SD 6.27). This variable was skewed due to the nature of the sampling frame; 30% of respondents reported less than one year of service, and these were primarily EMTs (n = 54).
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The demographic characteristics of this sample vary slightly from the National Registry of EMTs demographic data, insofar as this sample is slightly younger. According to the NREMT, the mean age of EMTs is 36.5 years and 35.1 years for paramedics (National Registry of Emergency Medical Technicians [NREMT], 2006), whereas in our sample, EMTs had a mean age of 29.8 years and paramedics had a mean age of 31.5 years. The gender distribution appears to be reasonably close to the overall population, where 65% of EMTs are male, and 73% of paramedics are male (NREMT, 2006).
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EMS-RIS Reliability Principal axis factoring with an oblique rotation revealed a four factor, 26item solution (KMO = .864; Bartlett’s Test χ2 = 2209.94, df = 325, p
