356EMF Shame and Error in EMS: A Qualitative Analysis of Culture and Attitudes in Prehospital Emergency Care

Abstract

The shame reaction is a highly negative emotional reaction shown to have long-term deleterious effects on medical providers’ mental health. Prior studies have focused on in-hospital personnel, so very little is known about what drives shame reactions in emergency medical services (EMS), a field with very high rates of post-traumatic stress disorder, burnout, anxiety, and depression.The objective of this study was to describe emotions, processes, and resilience associated with self-identified adverse events in the work of out-of-hospital providers. We conducted a qualitative study using a modified critical incident technique. Participants were voluntarily recruited from two EMS agencies in North Carolina: one urban and one rural. They provided an open-ended, written reflection in which they were asked to self-identify a particular event in their EMS career that felt emotionally difficult. In-person or video in-depth interviews about these events were then conducted in a semi-structured fashion using an iterative interview guide. The codebook was developed through a mix of inductive and deductive analysis strategies and discussed within the research team and a content expert for validation. Interviews were transcribed and data was analyzed following a thematic content analysis approach for types of cases identified as emotionally difficult, common emotional responses and coping mechanisms, and the lingering impact of these experiences on study subjects. Eight interviews were conducted with EMS personnel: five from an urban agency and three from a rural agency. Participants commonly identified complex medical cases as being emotionally difficult, which led to the most robust shame reactions. Shame reactions were more common when EMS providers committed self-perceived errors in patient care, whereas guilt reactions were more common when patient outcomes seemed “inevitable” despite any intervention. Common themes related to coping mechanisms included both personal mechanisms which tended to be less successful compared to interpersonal mechanisms, particularly when emotions were shared with colleagues. This reflected a perceived culture change within EMS in which sharing emotions with colleagues was seen as a departure from the “old school” where emotions tended to be kept to oneself. Feelings of inadequacy, low self-worth, and being “not good enough” were frequently identified as lingering emotions after difficult cases that were hard to move on from, corresponding to longstanding shame in these providers. Recovery and resilience varied but tended to be positively associated with a culture in which sharing with colleagues was encouraged, and personal introspection on root causes for the sentinel event. EMS providers often identify complex patient cases as those leading to emotions such as shame and guilt, with shame reactions being more common when a perceived error was committed. Coping mechanisms were varied, but individuals often relied on their co-workers in a sharing environment to adequately process their negative feelings, which was seen as a departure from past practices in EMS personnel. Our hope is that future studies will be able to utilize these findings to identify targets for intervention on negative mental health outcomes in EMS personnel.