DECLARATION

We declare this proposal is our original work and has not been submitted for an award or degree

in another unit.

___________________________________ _________________

JANE WANGARI ND’UNGU DATE

CO1S/8631/2008

___________________________________ _________________

PHYLLIS WACUKA KAGIINA DATE

CO1/0390/2008

RECOMMENDATION

This project has been submitted with my approval as the University supervisor.

___________________________________ ______________

i
ii
 ACKNOWLEDGEMENT

This research would not be possible without the instruction and guidance of our lecturer, Mr.

John Oteyo and our supervisor Mrs. Kamina. We would also like to acknowledge the help the

Red Cross administration which was very supportive while we collected our data, and Trevor

Mark whose help at Avenue Hospital was invaluable. Lastly, we would like to thank God with

whom all things are possible.

iii
 TABLE OF CONTENTS
DECLARATION.........................................................................................................................................i

ACKNOWLEDGMENT.............................................................................................................................ii

TABLE OF CONTENTS...........................................................................................................................iii

ABSTRACT................................................................................................................................................v

OPERATIONAL DEFINITION OF TERMS.............................................................................................vi

CHAPTER ONE: INTRODUCTION..........................................................................................................1

1.1 Background of the Study...................................................................................................................1

1.2 Statement of the Problem...................................................................................................................3

1.3. Purpose of the Study.........................................................................................................................3

1.4. Objectives of the Study.....................................................................................................................4

1.5. Research Questions of the Study......................................................................................................4

1.6. Significance of the Study..................................................................................................................4

1.7 Scope of the Study.............................................................................................................................5

1.8 Limitations of The Study...................................................................................................................5

CHAPTER TWO: LITERATURE REVIEW..............................................................................................6

2.1. Introduction......................................................................................................................................6

2.2. Theoretical Framework.....................................................................................................................6

2.3. Effects of Repeated Trauma Exposure..............................................................................................8

2.4. How Repeated Trauma Exposure Affects the Behavior of Ambulance Paramedics.........................9

2.5. Emotional Effects of Repeated Trauma Exposure on Ambulance Paramedics.................................9

2.6. Cognitive Effects of Constant Trauma Exposure on Ambulance Paramedics.................................10

2.7. Conceptual Framework...................................................................................................................11

CHAPTER THREE: METHODOLOGY..............................................................................................12

3.1 Introduction.....................................................................................................................................12

3.2 Research Design..............................................................................................................................12

3.3 Research Location...........................................................................................................................12

iv
 3.4 Target Population............................................................................................................................12

3.5 Sample Size and Sampling Procedure..............................................................................................12

3.6 Research Instrument........................................................................................................................12

3.7 Data Collection Procedures..............................................................................................................13

3.8 Data Analysis...................................................................................................................................13

3.9 Ethical Considerations.....................................................................................................................13

CHAPTER FOUR: RESULTS ANALYSIS AND PRESENTATION......................................................15

4.1 Introduction.....................................................................................................................................15

4.2 Demographic Data of The Sample...................................................................................................15

4.3 Results Presentation.........................................................................................................................15

4.1.1 How Repeated Trauma Exposure Affects the Behavior of Paramedics.....................................18

4.1.2 Emotional Effects of Repeated Trauma Exposure on Ambulance Paramedics.........................19

4.1.3 Cognitive Effect of Constant Trauma Exposure on Ambulance Paramedics............................21

CHAPTER FIVE: DISCUSSIONS, CONCLUSIONS AND RECOMMENDATION..............................23

REFERENCES..........................................................................................................................................26

v
 ABSTRACT
The research was carried out to determine the effects of repeated trauma exposure on
Ambulance Paramedics. The research sought to determine how repeated trauma exposure
affects the behaviour of ambulance paramedics, also the emotional and cognitive effects of the
repeated trauma exposure. The study sought to expand existing knowledge on the effects of
constant trauma exposure that ambulance paramedics experience in their line of work. The
study sought to establish the relationship between the constant incident exposure and
ambulance paramedic behaviour. Quantitative data was collected using questionnaires that
were administered by the researchers and a volunteer paramedic. Twenty ambulance
paramedics provided the sample of the population and they were purposively chosen from
paramedics at the Red Cross in South C and from Avenue hospital. Seventeen paramedics,
however, were the ones who filled the questionnaires. The data collected from the
questionnaires was coded and scored and analyzed using the statistical package for the Social
Sciences (SPSS). The findings were that exposure to repeated trauma will lead to changes in
the ambulance paramedics behavior, emotion and cognition. These findings will be beneficial
to the Red Cross society and Avenue Hospital implement strategies in helping the ambulance
paramedics cope with the trauma they are exposed to in their line of duty.

vi
 OPERATIONAL DEFINITION OF TERMS
CISM (Critical Incident Stress Management) -It is an adaptive short-term psychological
helping process that focuses solely on an immediate and identifiable problem. It includes crisis
management to post-crisis follow up.
Critical incidents and traumatic events- These are events that disturb or overwhelm on
individuals normal method of coping.
PTSD (Post Traumatic Stress Disorder) -The development of symptoms following on
extremely stressful experience or situation. The symptoms are normally recurrent and intrusive
recollections, images, thoughts or perceptions.

Trauma -Is an emotional wound or shock that creates substantial, lasting damage to the
psychological development of a person, often leading to neurosis.

vii
 CHAPTER ONE: INTRODUCTION
In this chapter, the researchers gave a brief background to the study. Previous research has been

highlighted to show the issue of trauma exposure on paramedics on a larger scale and therefore,

to justify this study and identify what its significance will be. In addition to this, the researchers

propose to investigate effects of repeated trauma exposure on ambulance paramedics in broad

terms and also the objectives and research questions of the study. The nature, time frame and

coverage of the study was also identified.

1.1 Background of the Study

Studies have been done round the world showing a link between witnessing traumatic events and

developing PTSD. Ambulance paramedics and emergency service personnel fall under the

category of those who regularly witness traumatic incidents .Studies in the UK have put the

prevalence of PTSD at 22%. (Bennet, Williams, Page, Hood & Woolard, 2003). Studies have

also found that the effectiveness at work changes as the person who has constantly been exposed

to traumatic incidents experience change in behavior and cognition (MC Farlane & Bryant,

2002). The research also looked at studies which had highlighted how the constant exposure

affects behavior. Some studies found a relationship between exposure to grotesque death and

drug abuse behavior. The researchers found that the degree of exposure to the traumatic event led

to a greater likelihood of alcohol abuse years after being exposed to the traumatic event. (Green,

Grace & Gleser, 1985). Professionals exposed to trauma have reported symptoms such as

avoidance behaviors, irritability and dissociation (Bride, 2007).

Stressful events that are not dealt with like repeated traumatic exposure may lead to unhealthy

coping such as numbing resulting in detachment, disinterest and emotional unavailability

(Ruscio, 2002). Self destructive and anti-social behavior may also be generated after the multiple

1
exposures to critical incidents (Mitchell & Bray ,1990). Apart from the effects on behavior,

studies conducted have shown that paramedics tend to retire early due to the stressful nature of

their job (Rodgers, 1998). In USA, the national average for a paramedic to stay on the job is 8

years (Belgium, 1999). This high stress results in burn out of the paramedics. It can also result in

PTSD. However, a study by Fullerton, MC. Carroll, Uisane, & Wright (1992) showed that

younger and single paramedics, paramedics who had previously had acute stress disorder and

those who had extensive previous critical incident exposure were more likely to develop PTSD.

Despite the potential negative consequences resulting from trauma exposure, little research has

been done locally. This leaves a gap to be filled, and therefore, this research sought to add new

knowledge to the field locally. The research studied ambulance paramedics on effects of

traumatic exposure on behavior, cognition and emotions. Does trauma exposure affect behavior,

cognition and emotions? If it does, what is the extent to which it affects them?

1.2 Statement of the Problem

Ambulance paramedics are usually first on the scene in response to incidents that are traumatic

in their nature. Constant exposure to such incidents has been shown to cause traumatic stress and

PTSD (Post Traumatic Stress Disorder). However, in Kenya, there has been a general view that

exposure to these incidents does not affect paramedics as it is the nature of their job. A study on

Post traumatic stress among Swedish ambulance personnel has shown there is a high prevalence

of PTSD symptoms. Though not all ambulance paramedics develop PTSD, those who do exhibit

several negative behavioral response such as; avoidance social withdrawal, interpersonal stress

and substance abuse. Some countries that have acknowledged that ambulance paramedics are

prone to PTSD and other stress related disorders have started offering debriefing services and

CISM programs have been implemented. In addition to that, they encourage peer support groups,

2
psychotherapeutic and support groups. However, such programs are not used widely in Kenya

despite research showing that there is need for some form of intervention. It is with this in mind

that the researches carried out a case study to establish the effects of exposure to trauma on

behavior, cognition and emotions of ambulance paramedics within the Red Cross South C and

Avenue Hospital.

1.3. Purpose of the Study

The aim of the study was to determine the effects of repeated trauma exposure on Ambulance

Paramedics. The researchers investigated in which way the repeated trauma exposure affected

the paramedics’ cognition, behavior and their emotions with an aim to determine if the constant

incident exposure will result in PTSD, trauma or depression, as several other studies had shown.

1.4. Objectives of the Study

The study aimed to achieve the following objectives:

i. To examine the effects of trauma exposure affects the behavior of ambulance

paramedics working with the Red Cross in South, C and Avenue Hospital Nairobi.

ii. To establish ways in which repeated trauma exposure affects the emotional affect of

ambulance paramedics in the Red Cross branch in South C and Avenue Hospital

Nairobi.

iii. To establish the cognitive effects of constant trauma exposure on the ambulance

paramedics in Red Cross, South C and Avenue Hospital Nairobi.

3
1.5. Research Questions of the Study

The following are the research questions the study will aim to answer:

(i) How does repeated trauma exposure affect the behavior of ambulance paramedics

working with the Red Cross in South C, and Avenue Hospital Nairobi?

(ii) What is the emotional impact of constant exposure to trauma on ambulance

paramedics in the Red Cross branch in South C, and Avenue Hospital Nairobi?

(iii) What is the effect of constant exposure to trauma on the cognitive processes of the

ambulance paramedics who work in Nairobi’s South C Red Cross branch and Avenue

Hospital?

1.6. Significance of the Study

The study sought to establish the effects of repeated trauma exposure on ambulance paramedics

locally; it looked at how it affects their cognitive processing, their emotions and in turn how that

affects their behavior. The study’s findings highlight the need of intervention and prevention

strategies that can be applied to ambulance paramedics. The primary beneficiaries of the study

are the ambulance paramedics who will be prepared to deal more effectively with the traumatic

incidents and, the Red Cross and Avenue Hospital which will benefit by the great efficiency of

the paramedics and less time taken off work.

1.7 Scope of the Study

The study was carried out in the Red Cross branch located in South C, Nairobi and in Avenue

HealthCare located in Parklands. Data was collected during the months of September and

October 2013. The variables that were included in the study were; emotions, cognition and

behavior.

4
1.8 Limitations of the Study

Some of the information given may have been incorrect.

5
 CHAPTER TWO: LITERATURE REVIEW

2.1. Introduction
This chapter presents the current stage of knowledge on the nature of the relationship between

exposure to traumatic events in people’s lives and how it affects their behavior, cognition and

emotions. The review looks at previous literature on related topics and it assisted the researchers

to see what remains to be done in the area of study. The research studied seventeen ambulance

paramedics both from the Red Cross and Avenue HealthCare, to determine the effects of the

repeated exposure to traumatic events. Does it affect their behavior? If it does to what extent

does it affect it? In which way does it affect their emotional expression and their cognition?

2.2. Theoretical Framework

The researchers used the Constructivist Self Development Theory. It explains the concept of

vicarious trauma where people who are indirectly exposed to trauma are negatively affected by

it. The theory uses the example of therapists and counselors who have worked with trauma

victims, and end up experiencing depression and or trauma. The researchers, therefore, used this

theory to expand its scope to include ambulance paramedics who had not been previously

considered.

The constructivist self development theory is a theory proposed by Laurie Anne Pearlman. It

proposes that individuals possess an inherent capacity to construct their own personal realities as

they interact with their environment. Individuals construct these realities based on their

perceptions and schemas (Trippany, Kress & Wilcoxon, 2004). Schemas are complex cognitive

structures; mental frameworks including beliefs, assumptions and expectations about self and the

world that enable individuals to make sense of their world. Symptoms of trauma are seen as

cognitive adaptations to the events, when individuals are exposed to events that do not fit their

6
current perceptions of reality they may develop irrational or distorted beliefs to protect

themselves from the harm caused by the trauma. Paramedics may experience disruptions in their

schemas about self and the world when they constantly come into contact with traumatic events,

the changes to their schemas may be subtle or shocking. There are themes in schema change,

specifying the role of the person’s social and interpersonal context in facilitating or blocking this

process and emphasizing the possibility of positive refraining of the trauma and post traumatic

growth Brewin & Holmes (2002). So according to this theory there are five components of self

which can be potentially affected by exposure to traumatic material these are: frame of reference,

self-capacities, ego resources, psychological needs and cognitive schemas, and memory and

perception.

Also key to the theory of constructivist self development is the concept of vicarious trauma, this

a transformation in the self when there’s an empathetic engagement with traumatized clients and

their reports of traumatic experiences. Vicarious trauma is less intense than direct trauma.

However, individuals still experience the effects of trauma. When it was proposed it dealt mainly

with psychotherapists however it has been later used to apply to other groups, such as health

care providers (Madrid & Schacher, 2006) and first responders (Shah, 2010a). This means in the

case where an emotional connection with the victim is present, the ambulance paramedic will be

likely to develop vicarious trauma.

2.3. Effects of Repeated Trauma Exposure

Exposure to traumatic events can lead to continued physiological, behavioral non threatening

stimuli (Resnick, Acierno, & Kipatrick, 1997). These cues involve a wide range of stimuli and

not just the specific event and environment. Reminders of the event may lead to an acute

autonomic nervous system arousal that may be as strong as when exposed to the initial trauma

7
(Pitman, Orr & Shaler, 1993). In other words, a person who has been exposed to a traumatic

event is prone to resurgence when re-exposed to people, places or things that evolve

recollections of the event. This triggered reminder is not time limited and can be prevalent years

after the initial trauma exposure. Research has demonstrated that exposure to severe

psychological distress, as occurs during major distress, combat operations and other life

threatening events can lead to long-term psychological trauma. Green, Grace & Gleser (1985)

found a relationship between exposure to grotesque death and an alcohol abuse diagnosis. They

also found that the greater the degree of involvement in rescue efforts such as exposure to burned

and mutilated bodies, the greater the likelihood of alcohol abuse years after exposure to the

traumatic event. It is possible that the positive correlations between trauma severity and alcohol

problems do in fact reflect on association between PTSD and alcohol abuse because trauma

severity is positive associated with the emergence of PTSD symptoms. Thus some researchers

have suggested that or adverse psychological reaction to trauma may better account for the

increased abuse of alcohol following exposure to trauma (Lacoursier & Cayne, 1984). Further

research on exposure to critical incidents found that self destructive and anti-social behaviour

may also be generated after exposure to a personally disturbing incident (Mitchell & Bray,

1990). Hospital social workers are also exposed to patients who have experienced traumatic

events or illness (Dane & Chackes, 2001) and need to address their patient’s pain and trauma as

well as their own reactions and feelings. This can be difficult in a hospital setting that allows

little time for processing these reactions (Pockett, 2003) and frequently preludes meeting

personal needs because of the fast pace of the job (Dane & Chankers 2001). The bottom line is

that exposure to life threatening and catastrophic experiences, whether in the context of war,

8
crime, distress or accidents has lasting consequences for many individuals (Helzer, Robins &

McEvoy, 1987).

2.4. How Repeated Trauma Exposure Affects the Behavior of Ambulance Paramedics
Research has suggested that numbing used by emergency respondents to cope with stressful

events may result in disinterest, detachment and emotional unavailability leading to poorer

quality relationship (Ruscio, 2002). A study by Rogers (1998) explored the relationship between

early retirement of emergency medical services professionals and job related mental and physical

stress. The study concluded that emergency medical services personnel did exhibit higher rates

of early retirement than other healthcare professionals primarily due to high levels of mental and

physical stress. The national average in USA for a paramedic to stay on the job is 8 years (Debra,

1999). The high stress level of a job means a high level of burn out.

2.5. Emotional Effects of Repeated Trauma Exposure on Ambulance Paramedics

A study conducted by Fullerton (2001) showed that emergency medical services personnel

exposed to a critical incident who received a diagnosis of acute stress disorder were 3.93 more

times likely to be depressed seven months following the incident. Emergency medicals service

personnel who are younger and single were more likely to develop acute stress disorder and

those exposed to critical incidents and had extensive previous critical incident exposure or acute

stress disorder were more likely to develop PTSD. In a study by Regehr, Goldberg & Hughes

(2002) where levels of depression were measured in ambulance personnel, it was found that

2.3% of respondents were suffering from severe levels of depressive symptoms, 5.8% were

experiencing moderate to high levels of symptoms, and 12.8% had mild to moderate level

symptoms of depression. In a study done in Wales, the prevalence of anxiety cases was 22% and

depression cases was 10%, as measured with the Hospital Anxiety and Depression Scale.

9
2.6. Cognitive Effects of Constant Trauma Exposure on Ambulance Paramedics
Cognitive symptoms of PTSD and trauma are intrusive thoughts and memories of the event,

visual images of the event, nightmares, poor concentration and memory, disorientation, and

confusion. Intrusive memories of the event are common in emergency service workers. Reports

of flashbacks and night terrors were recorded in a study of ambulance paramedics by Regehr,

Goldberg & Hughes, (2002). Thompson and Suzuki (1991) randomly selected forty ambulance

workers from the London Ambulance Service, they were studied using the Impact of Event Scale

and the General Health Questionnaire, and their samples scored high on the intrusion scale of the

I.E.S. In a study by Clohessy & Ehlers of fifty six ambulance service workers, 49% of the

respondents reported experiencing intrusive memories.

10
2.7. Conceptual Framework

Repeated Trauma Exposure

Extraneous Variables-
Intervening Variables-
Social support
Alcohol abuse
Past trauma
Antisocial Behavior
Family history of depression

Cognitive Effects Behavioral Effects Emotional Effects

PTSD

Depression

As shown in the conceptual frame work above, repeated trauma exposure affects the paramedics’

behavior, cognition and emotions causing depression and in some instances PTSD. Social

support and past trauma are extraneous variables. They affect the probability of developing

depression and PTSD. That is, a paramedic with low social support or a paramedic with past

trauma is more likely to develop depression or PTSD. Alcohol abuse and anti-social behavior on

the other hand are the intervening variables in this study. This is because they can be caused by

repeated exposure to trauma and when they are used as coping mechanisms, they can worsen

depression and PTSD.

11
 CHAPTER THREE: METHODOLOGY

3.1 Introduction

This chapter will discuss the research design which will be descriptive. It also states the research

location; which will be the Red Cross South C branch , and the population that the research will

target. Also in this chapter are the sampling procedures that the researchers will use in the study,

which will be purposive sampling procedure. The research instrument, questionnaires, are

discussed in detail. After having acquired their required sample size, the researchers will

administer questionnaires to collect data. In this chapter the researchers also discuss how the data

will be analyzed and conclude with the ethical considerations of the study.

3.2 Research Design

The research was descriptive in nature; it sought to describe what the effects of repeated trauma

exposure are in ambulance paramedics currently. It is not experimental and none of the variables

were manipulated however it studied the relationship between the variables. This research will

sought to expand the existing knowledge on repeated trauma exposure on ambulance paramedics

in Kenya.

3.3 Research Location

The researchers conducted the study at the Red Cross branch located in Bellevue, South C along

Mombasa road and at Avenue Healthcare, Parklands Nairobi.

12
3.4 Target Population

There are twenty two ambulance paramedics working within the South C branch of the Kenyan

Red Cross, out of the paramedics ten were chosen to participate in the study, however only seven

of the ten answered the questionnaires. There are twelve paramedics in Avenue Healthcare and

out of these; ten were chosen to participate in the study.

3.5 Sample Size and Sampling Procedure

As it is a case study seventeen respondents were used to participate in the study. The participants

were chosen by the researchers out of those the total population so as to ensure that the ratio of

men to women is proportionate. The researchers used a representative sample in regard to the

total number of men and women working as ambulance paramedics in the two organizations.

3.6 Research Instrument

The researchers used questionnaires to collect data among the participants. The questionnaires

were of a closed format. Each question contained choices from which the respondent was

required to choose an answer from. The first part of the questionnaires contained questions

asking demographic information such as gender, age and how long they have worked as a

paramedic.

The second part of the questionnaire contained questions designed to reveal depression. These

questions were derived from the Hamilton Depression Scale and the Personal Health

Questionnaire (PH9) and slightly altered to fit the setting. This was to aid in validity and

reliability as both scales have been rated valid and reliable.

Three questions were from the Warwick-Edinburgh Mental Well-Being Scale; these questions

were being used as control questions to prove the internal consistency of the questionnaire. The

13
researchers also gave the questionnaire to their peers and the project supervisor to confirm the

face validity. To ensure validity, the items in the questionnaire will be guided by the research

question. The reliability of the questionnaires will be ensured by using the split half method; this

will help establish the internal consistency of the items.

3.7 Data Collection Procedures

The researchers obtained an introduction letter from the university to the Kenyan Red Cross

Society stating that the researchers were students from Kenyatta University and they wanted to

collect data in their organization for research purposes.. The questionnaires were administered to

the individual ambulance paramedics by the two researchers and a volunteer paramedic, and

material such as pens to answer the questionnaires were provided. The respondents were briefed

on how long it would take them to fill in the questionnaire and the administrator waited until it

was filled before leaving with it.

3.8 Data Analysis

There were fifteen items in the questionnaire which were divided into three sections. The highest

score in any question was four marks while the lowest score was zero. In total, the questionnaire

was scored on a scale of 0-60. 0, which is the lowest score represented no depression, 1-15

represented a normal emotional state, 15-30 showed moderate depression, 31-45 was used to

reveal severe depression, while 45-60 represented very severe depression.

The data after analysis was presented using bar graphs and pie charts.

14
3.9 Ethical Considerations

The researchers obtained informed consent of the respondents and provided a document asking

for their voluntary participation in the study which informed them of the intent to use their

responses for research purposes.

The researchers sought to protect the confidentiality of the individuals who participate by asking

them not to provide their names on the questionnaires they filled in.

The researchers did not disclose any information revealed in the questionnaire

The researchers sought to show respect to all the participants and used language that was free

from bias and showed sensitivity to gender and ethnicity.

Because of the nature of the question, the respondents were assured that if any psychological

harm was inflicted because of the study, the researchers shall offer debriefing and refer the

respondents to a counselor if need be.

15
 CHAPTER FOUR: RESULTS ANALYSIS AND PRESENTATION

4.1. Introduction

The research study is on the effects of repeated trauma exposure on ambulance paramedics. The

questionnaires were distributed to 20 participants. There was a 90% overall response rate (n=18).

The respondents consisted of 17 ambulance paramedics and an ambulance technician. Only the

seventeen questionnaires filled by the paramedics were analysed. This chapter discusses the

results of the questionnaires as a whole: showing the overall effect of trauma exposure and, the

results of each objective, that is; the effects of constant exposure to trauma in paramedics’

behavior, cognition and emotions.

4.2. Demographic Data Of The Sample

The following table shows the demographic data of the paramedics who work at avenue hospital

Table 1

AVENUE HOSPITAL

PARTICIPANT AGE MARITAL DURATION SCOR INTERPRETATION

S BRACKE STATUS WORKING E

T AS A

PARAMEDIC

1 26-40 Divorced 5 years 32 Severe depression

2 41-55 Married 9 years 23 Moderate depression

16
3 25 or under Married Six months to 17 Moderate depression

a year

4 56 or older Divorced 15 years 24 Moderate depression

5 25 or under Single Less than 6 22 Moderate depression

months

6 26-40 Single 4 years 22 Moderate depression

7 25 or under Single Less than 6 18 Moderate depression

months

8 26-40 Single Six months to 23 Moderate depression

a year

9 25 or under Single Less than 6 37 Severe depression

months

10 25 or under Single Six months to 38 Severe depression

a year

17
The following table shows the demographic data of paramedics working at the Red Cross.

Table 2

DATA COLLECTED RED CROSS, SOUTH C

PARTICIPANTS AGE MARITAL DURATION SCORE INTERPRETATION

BRACKET STATUS WORKING

AS A

PARAMEDIC

1 26-40 Married 6 years 10 normal

2 26-40 Married 3 years 24 Moderate depression

3 26-40 Married 6 months to a 25 Moderate depression

year

4 26-40 Married 6 years 18 Moderate depression

5 41-55 Married 3 years 19 Moderate depression

6 41-55 Married N/A N/A

7 26-40 Single 6 months to a 7 normal

year

8 26-40 Married 3 years 13 normal

18
As can be seen in the Table 1 and 2 above, out of the seventeen paramedics; 9 were married, 7

were single, and 2 were divorced.

5 paramedics were of the age group ‘25 or under’, nine paramedics were between 26-40 years,

three of the respondents were between the age of 41-55, and one respondent was in the age group

of 56 or older.

47% of the paramedics were men (n=8) and 53% were women (n=9).

Their average job experience in ambulances amounted to 3.4 years ranging from 5months to 15

years.

19
4.3. Results Presentation

The following figure shows the paramedics and the scores they got in the questionnaire.

Figure 1

As seen in the figure 1 above, out of the 17 paramedics, 82.4% scored 15 or more on the

depression scale, while 17.6% scored 30 or more on the scale. Scores over 15 indicate moderate

depression while the scores above 30 indicate severe depression.

There were three research objectives investigating the effect of constant exposure to trauma on

paramedic’s emotions, behavior and cognition.

The first objective was to find out the effect of constant exposure to trauma on behavior. From

the research findings, 52.9% of paramedics (n=9) scored 10-20 on the scale thus displaying

20
severe symptoms of depression, which shows that the trauma had a very severe effect on the

paramedics behavior.

The second objective was to determine ways in which repeated trauma exposure affects the

emotions of ambulance paramedics. 23.5% of the paramedics who filled the questionnaire (n=4)

scored 10-15 on the scale. This is a severe effect to the paramedic’s emotional affect in response

to the constant exposure to trauma.

In the third objective, however, which was to establish the effects of repeated trauma exposure

on cognition of ambulance paramedics; 1 paramedic displayed severe cognitive symptoms of

depression. 70.5% (n=12) had moderate cognitive symptoms of depression

4.3.1. How Repeated Trauma Exposure Affects The Behavior of Paramedics

The following figure is a percentile representation of the data collected for the first objective:

how repeated trauma exposure affects the behavior of paramedics.

Figure 2

Effect of Trauma on Behavior Represented in

Percentages

23.52%
29.41%

47.05%

21
As can be seen in the figure 3 above, out of the 17 paramedics who filled the questionnaire,

11.76% (n=2) had low behavioral symptoms of depression, 35.29% of the respondents (n=6)

showed moderate effects of trauma on their behavior, 47.05% (n=8) displayed severe effects of

trauma on their behavior.

The figure 4 below shows the score attained by each ambulance paramedic in terms of the

behavioral effects.

Figure 3

behavioral effects

16
14
12
10
Scores

8 behavioral effects
6
4
2
0
1 3 5 7 9 11 13 15 17
Ambulance Paramedics

The average score in the behavioral response section was 9.11 (SD 3.5).

22
4.3.2. Emotional Effects of Repeated Trauma Exposure on Ambulance Paramedics

The figure below represents the emotional effect of trauma represented in percentages.

Figure 4

Emotional Effect of Trauma Represented in

Percentages

5.88% 11.76%

47.05% 35.29%

The second objective aimed to determine the extent to which trauma affects the emotions of the

ambulance paramedics.

The average score in the emotional response section was 6.47 (SD 3.45). Out of the 17

paramedics 29.41% (n=5) presented with low emotional symptoms of depression, 47.05% (n=8)

showed a moderate emotional response to repeated trauma exposure, and

23.52% (n=4) showed a high emotional response to the constant exposure to trauma. This is as

illustrated in figures 5 above.

23
The figure 6 below shows the total score each paramedic had in terms of emotional effects of

trauma.

Figure 5

Emotional Effects of Trauma

16
14
12
10
Scores

emotional effects
8
6
4
2
0
1 3 5 7 9 11 13 15 17
Ambulance Paramedics

4.3.3. Cognitive Effect of Constant Trauma Exposure on Ambulance Paramedics

The figure 7 below represents the effect of trauma exposure on cognition as represented in

percentages.

Effect of Trauma Exposure on Cognition

Represented in Percentages

5.88%
17.64%
5.88%

70.50%

Figure 6

24
The aim of the third objective was to establish the effect of constant exposure to trauma on

cognition.

The average score was 6.35 (SD 3.26). 17.64% (n=3) of the respondents had a low cognitive

effect to the repeated trauma exposure. 70.5% (n=12) had a moderate reaction to the exposure to

repeated trauma. 5.88% (n=1) showed a high response to the exposure to repeated trauma while,

5.88% (n=1) had no cognitive symptoms of depression. This is illustrated in figure 7 above.

The bar graph in figure 8 shows the total score each paramedic had on the cognitive effects of

constant trauma exposure.

Figure 7

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4.1.1 How Repeated Trauma Exposure Affects the Behavior of Paramedics

The questions in this section- Section A- were designed to measure whether the constant
exposure to trauma influenced the paramedic’s behavior. There were five questions in total with
a total score of 20; which was therefore the highest score. The lowest score possible was 0. The
average score in the behavioral response section was 9.11 (SD 3.5). Of the 17 paramedics who
filled the questionnaire, 11.76% (n=2) had low behavioral symptoms of depression, 35.29% of
the respondents (n=6) showed moderate effects of trauma on their behavior, 47.05% (n=8)
displayed severe effects of trauma on their behavior. This is as shown in figure 2 below.

Figure 8

Effect of Trauma on Behavior Represented in

Percentages

23.52%
29.41%

47.05%

Figure 9
behavioral effects

16
14
12
10
Scores

8 behavioral effects
6
4
2
0
1 3 5 7 9 11 13 15 17
Ambulance Paramedics

26
The figure 3 above shows the total score attained by the 17 paramedics in Section A of the
questionnaire.

4.1.2 Emotional Effects of Repeated Trauma Exposure on Ambulance Paramedics

The questions in section B of the questionnaire were designed to discover the extent to which
trauma affected the emotions of the ambulance paramedics. The highest score that could be
attained was 20 (very severe), while the lowest score was 0 (no emotional effect). The average
score in the emotional response section was 6.47 (SD 3.45). Out of the 17 paramedics 29.41%
(n=5) presented with low emotional symptoms of depression, 47.05% (n=8) showed a moderate
emotional response to repeated trauma exposure, and 23.52% (n=4) showed a high emotional
response to the constant exposure to trauma. This is as illustrated in figures 4 below.

Figure 10

Emotional Effect of Trauma Represented in

Percentages

5.88% 11.76%

47.05% 35.29%

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The figure 5 below shows the total score each paramedic had in Section B of the questionnaire.

Figure 11

Emotional Effects of Trauma

16
14
12
10
emotional effects
Scores

8
6
4
2
0
1 3 5 7 9 11 13 15 17
Ambulance Paramedics

4.1.3 Cognitive Effect of Constant Trauma Exposure on Ambulance Paramedics

There were five questions in this section - section C- of the questionnaire. Those questions were
measuring what the cognitive effect of constant trauma exposure is in paramedics. The average
score was 6.35 (SD 3.26). 17.64% (n=3) of the respondents had a low cognitive effect to the
repeated trauma exposure. 70.5% (n=12) had a moderate reaction to the exposure to repeated
trauma. 5.88% (n=1) showed a high response to the exposure to repeated trauma while, 5.88%
(n=1) had no cognitive symptoms of depression. This is illustrated in figure 6 below.

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Figure 12

Effect of Trauma Exposure on Cognition

Represented in Percentages

5.88%
17.64%
5.88%

70.50%

The bar graph in figure 7 shows the total score each paramedic had in this section, as shown
below.

Figure 13

Cognitive Effects

16
14
12
10
Scores

8 cognitive effects
6
4
2
0
1 3 5 7 9 11 13 15 17
Ambulance Paramedics

29
 CHAPTER FIVE: DISCUSSIONS, CONCLUSIONS AND RECOMMENDATION
Emergency workers, including ambulance paramedics must cope with a variety of duty related
stressors including traumatic incident exposure. This study presented a better understanding of
the effects of repeated trauma exposure on ambulance paramedics. The study achieved a
substantial rate and 90% of the ambulance paramedics completed the questionnaires. From the
research, it is evident that a substantial proportion of the ambulance paramedics experienced post
traumatic stress. The results support the conclusion that ambulance paramedics are at risk of
developing PTSD when they are repeatedly exposed to traumatic events. Ambulance personnel
endure high daily stress and are repeatedly exposed to human suffering and they work in highly
hazardous environments. They have to cope with death, grief and events outside the normal
range of human experience, situations that can be risk factors for inducing PTSD reactions. The
stress reactions described were reported as consequences of regular daily duty and the personnel
were representative of the ambulance stations around Nairobi.

Stress reactions are part of the daily routine work performed by ambulance personnel and the
impacts of these symptoms are scarcely highlighted. However, some research has shown that the
everyday work can lead to occurrence of traumatic stress among rescue workers. Findings from
this research support previous research. The study found that 17.6% of the ambulance
paramedics displayed symptoms showing severe depression, while 82.4% showed symptoms of
moderate depression. This is in comparison to the study conducted by Fullerton(2001) which
showed that emergency medical services personnel exposed to a critical incident who received a
diagnosis of acute stress disorder were 3.93 more times likely to be depressed seven months
following the incident. Also, in a study by Regehr, Goldberg &Hughes(2002) where levels of
depression were measured in ambulance personnel, it was found that 2.3% of the respondents
were suffering from severe levels of depressive symptoms, 5.8% were experiencing moderate to
high level of symptoms and 12.8% had mild to moderate level symptoms of depression. This
shows that the Kenyan average for depression was high in contrast to those studies.

According to the study completed, 52.9% of the paramedics showed severe behavioral symptoms
of depression, 23.5% displayed severe emotional symptoms of depression and 5.88% displayed
severe cognitive symptoms of depression. This showed that paramedics displayed a higher
degree of behavioral symptoms than emotional symptoms. Cognitive symptoms were the least
reported. This means that there is a high probability of the paramedics’ behavioral symptoms
affecting their work. The findings were that exposure to repeated trauma will lead to changes in
the ambulance paramedics behavior, emotion and cognition. These findings will be beneficial in
that they will help the Red Cross society and Avenue Hospital implement strategies to help the
ambulance paramedics cope with the trauma they are exposed to in their line of duty.

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The researchers were using the constructivist self development theory. It explains the concept of
vicarious trauma where people who are indirectly exposed to trauma are negatively affected by
it. The findings of this research support this theory since it is clear that exposure to traumatic
incidence of ambulance paramedics affects them negatively in terms of behavior, emotions and
cognitions. The high prevalence of post traumatic stress symptoms in ambulance paramedics
indicates an inability to cope with stress in daily work. The strong relation between post
traumatic stress and Sense of Coherence Scale may be useful in predicting vulnerability for post
traumatic symptoms among recently employed ambulance service personnel. The outcome of the
study proposes some measures to prevent PTSD and give further support to ambulance workers
with PTSD symptoms. Information has to be spread among management and personnel to
increase awareness of PTSD symptoms. The management has to identify those who suffer from
post traumatic stress and take action accordingly. The lack of coping strategies may facilitate
stress symptoms and other mental and psychological illnesses. Groups with high level of stress
are vulnerable to changes in the environment. Some ambulance paramedics have such high stress
levels that they need professional counseling. To prevent or reduce the upcoming of PTSD
symptoms it must be possible to take leave of absence or for a period time be transferred to non-
emergency duty. That change, however, could be difficult because of an increased work load in
the ambulance stations. The management has to take into consideration that a change in the
ambulance organization also needs to be done. In addition measures such as debriefing after
traumatic incidents can be employed. Avenue Health Care has recently made it part of their
program to debrief paramedics, research needs to be done later to establish whether it lowered
the rate of depression.

From the research done, there is probably a risk of under reporting because ambulance
paramedics with stress symptoms may avoid filling in the questionnaires. There is also the
probability of emergency personnel under-reporting their psychological symptoms because in the
role of helping others they deny that they are vulnerable to the sane risks as the victims. An
important factor to predict PTSD reaction is continuing exposure, intensity and duration of
trauma. In this study, there is some information about quality aspects of trauma but no deeper
analysis has been performed. There is also a strong connection between the number of years in
the ambulance service and symptoms of stress and depression. These findings can perhaps be
related to burnout reactions, though no such investigation was made in this study. The fact
emphasizes the need for deeper understanding of the psychological outcome of ambulance work.
During nearly every duty day, ambulance paramedics are exposed to experiences that could be
characterized as traumatic. However, these are not the only possible emergency work related
outcomes. For example, research findings evidenced that emergency personnel reported positive
post trauma changes (post traumatic growth). This can be the result of the experience of
occupational trauma (Shakespeare-Finch, 2003). Stamm (2005) introduced the concept of
compassion satisfaction, defined as the benefits that individuals derive from working with
traumatized or suffering persons- i.e., positive feelings about helping others, finding meaning in
one’s efforts and challenges, fulfilling one’s potential, contributing to the work setting and even

31
to the greater good of society, and the overall pleasure derived from being able to do one’s work
well.

From the findings of this research, it is evident that future research is needed in this and other
related areas to understand effects of repeated trauma exposure on ambulance paramedics better.
It is suggested that future research studies adopt a longitudinal design as these studies may offer
greater insight as they provide greater richness of detail. In addition, future studies may want to
introduce a multi-method approach of assessment. This enables the researcher to obtain a fuller
understanding and analysis of the gathered data (Welman& Kruger, 2001). Using both
qualitative and quantitative research methods accounts for the weaknesses of either method in
isolation therefore improves the overall research design and ensures greater reliability and
validity of the data.

In conclusion, helping traumatized people is gratifying (Figley, 1995). However, in order to

benefit from the rewards that trauma work has to offer, ambulance paramedics should be made
aware of the negative effects this type of work may evoke, so that they can be prepared for them.
It is thus recommended that the occurrence of post traumatic stress in this line of work be
recognized, acknowledged and normalized as a process upon entering this field. The researchers
emphasize that those who risk their lives and welfare to assist others should not be neglected.
The hope is that findings from the study will enable ambulance paramedics to continue with their
valued and important service and remain satisfied in their contribution to society. Emergency
service organizations must be prepared with employee assistance programs that are willing to
reach out to families who may be affected by these problems. There is also need for pro-active
education so that ambulance paramedics and their colleagues and supervisors can identify
potential risk situations and involve formal support systems.

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