Grief in Paramedicine

As Avraham, Goldblatt & Yafe (2014) explain, a paramedic is often exposed to life threatening and traumatic incidents. Being present at these incidents frequently can cause serious damage to their wellbeing, which in turn can lead to disastrous changes in mental and physical health. Therefore, in order to maintain their wellbeing, it is important for a paramedic to have coping mechanisms for dealing with stress and grief. Everybody experiences grief, it is a normal human response. However, the process in which grief is carried out is diverse depending on the background of a person (Buglass, 2010). For a paramedic to ensure they are fully able to support family and friends of the deceased in the process of grief, they should be aware of the culture and religion of these people (Clements et al., 2003).

Stress is a major implication of being a paramedic, and it can present itself in many ways. Being involved in incidents where death or abuse has occurred can cause post-traumatic stress symptoms, as well as have a detrimental effect on mental and physical wellbeing (Bryant & Harvey, 1996). It is often the small events that will stay with a paramedic for life, such as the death of a small child due to abuse or the lonely death of an elderly person who has not seen their family for years (Regehr, Goldberg & Hughes, 2002). The development of post traumatic stress symptoms due to being exposed to the death of these individuals is called ‘vicarious traumatisation’. Vicarious traumatisation destructively impacts the paramedics mental and physical wellbeing as it gives them an adverse perception of the world (Pearlman & MacIan, 1995) as well as assisting in the development of sleep disorders and fear (Chrestman, 1999). However, vicarious traumatisation is not the only stress paramedics deal with. The inability to control a situation can also cause major stress within the paramedic sector and can cause clinical error. The demand for paramedics to recognize a problem and be able to act immediately often makes them question themselves; especially if the resolution to the problem is unknown, which can lead to inability to control a situation (Avraham et al. 2014). Organisational stress is also vast. Shift work is the common cause of organisational stress as hours are constantly changing which causes sleep deprivation. Sleep deprivation is seen in a variety of shift workers including nurses, police officers and paramedics. (Sofianopoulos, Williams & Archer, 2010)

High levels of stress cause physical and behavioural changes in an individual. When stress occurs, the brain sends a distress signal via the nervous system to the adrenal glands. The adrenal glands then release adrenaline. Adrenaline is what causes the ‘fight or flight’ response, which are the physical symptoms of stress (http://www.tuw.edu/content/health/how-stress-affects-the-brain/s.), These symptoms include rapid breathing and an increased blood pressure and heart rate. McEwen (2017) states that when an individual is being exposed to high amounts of stress, this response becomes overused which results in ‘allostatic overload’. He continues to say that allostatic overload causes the cardiovascular, immune and metabolic systems to become damaged which may cause overindulgence in fatty foods, loss of sleep, alcoholism and cause onset depression and anxiety. Chronic stress may also result in a paramedic detaching themselves from loved ones or taking extended amounts of time off work.

The realization that there is a diverse amount of stress in the paramedic sector allows the point of coping mechanisms to be an important part of maintaining wellbeing. Often reconstructing and reviewing an event with an associate can help relieve some of the stress. This is because the paramedic can often see where they have gone wrong in the case of clinical error (Jonsson & Segesten, 2004). If clinical error has not occurred, it gives the paramedic reassurance that what they had done was correct and assists the feeling of control and confidence to make a reappearance (Regeher et.al, 2002). In New Zealand, St. John offer a peer support system and critical incident debriefing. There are different types of debriefings, they each have a sole purpose. For example; defusing tends to allow the paramedic to express their feelings straight after a critical event, this encourages mental and physical support from other crew members and helps the individual to wind down. Operational debriefing on the other hand, is normally taken by an experienced individual who will review the incident and explain what could have been done differently. Paramedics often use this to help with decisions in future jobs(St. John n.d). Having time to rest and wind down at the end of the shift is significantly important to greatly reduce the chance of developing chronic stress (Timmermans, 1999). Talking to loved ones and attaining support from them after a critical event also decreases stress symptoms. (Regehr, Hemsworth, & Hill, 2001). While on the scene of a critical event, taking a quick pause to visualise what to do next can help refresh the mindset and hinder the stress of the event to take over (Regehr et.al, 2002).

Because paramedics are frequently being exposed to death, it is important that they understand the process of grief and recognize that diverse cultures have varied responses to it (Buglass, 2010). There are many theories for the process of grief, most of which are very similar. According to Kubler Ross (1969), grief has five stages. These stages are: denial, anger, bargaining, depression and acceptance. Although this theory has been extensively used, it has been criticized quite often as people frequently perceive it to be following a set outline or, as Corr (1993) explains, more like ‘a defence mechanism’. Baier and Bueschel (2012) saw the Kubler Ross theory to be a good one, however believed that remodelling it could help an individual to realise that the reaction to grief differs within everyone. Together, they established the ‘pinball model’ which is very similar to the Kubler Ross theory. Instead of following a certain pattern however, they understood grief to bounce between the first four stages of the theory before acceptance could occur. Hence the name ‘pinball model’. Linderman (1944) had a similar theory to Kubler Ross, however explains that for acceptance to occur, the grief-stricken must emotionally disconnect themselves from the deceased and learn to live life without them. Buglass (2010) writes that the theory of Bowlby (1973) reinforces the process that Linderman imposes as it explains the need for humans to attach themselves to other people and the emotional suffering that occurs when this bond is unexpectedly broken.

Communicating a death notification is a challenging task that paramedics perform frequently (Morrison et al, 2010), so it is important that a paramedic learns how to do this respectfully. In a study carried out by Smith-Cumberland and Feldman 2006, it was found that the grief process of a family could be affected by the way a paramedic acted. Clements et.al (2003) explain that the cultural beliefs of an individual can determine how long someone grieves for and how it impacts them. Paramedics performing certain strategies can often support the grieving process, providing physical contact when suitable is one of these approaches (Bledsoe, Porter & Cherry, 2007). The Latino culture consider human touch to be respectful towards the grieving, so holding the hand of a family member or touching their arm whilst delivering the death notification would assist in the process of grief (Shaefer, 1999). Hobgood et.al (2013) explained that using an organized model such as the mnemonic GRIEV_ING can support the paramedic to ensure a death notification is given respectfully and clearly which positively assists in the grieving process. GRIEV_ING consists of nine structured steps that will assist in the death notification. These steps include gathering the family and friends together, being sure not to exclude anyone. Next, the paramedic must identify themselves and their role in the events that took place, as well as identifying the patient by their name. Following this, paramedics can explain to the family what happened, before verifying that the patient has died. Goldberg & Boustead (1998) state that it is important not to use any euphemisms of death and to be very clear that the patient has died. Giving the grieving personal space is the next important stage as it gives them the opportunity to take in the what has happened. Asking if the family have any questions, giving them the opportunity to see the body, enquiring what they would like done with the possessions of the deceased and giving them contact information for support systems are the last part of the GRIEV_ING mnemonic. Clements et.al (2003) writes that talking to the grieving family and enquiring about any beliefs they may have surrounding the deceased will help assist in the course of grief, as this may assist in them be certain that they will not offend. A Native American tribe named the Navajo tribe believe that the grieving process should only take 4 days, afterwards the deceased should no longer be mentioned as it hinders the spirit from moving on and potentially harms the living relatives of the departed. Asking the family what they would like done with the deceased belongings is important with the Navajo as they believe all of their possessions must be destroyed in order for the spirit to move on. A paramedic encouraging the family to grieve could possibly offend as well as delay the progression of grief (Clements et al., 2003).

In conclusion, a paramedic will frequently be exposed to traumatic events, often resulting in death. Therefore, not only is it important for coping mechanisms to be put in place to maintain personal wellbeing, but it is also significant to understand the cultural differences in the grieving process. Failure to do so can be catastrophic for not only the paramedic, but also the family of the deceased.