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Systematic review of the personality profile of paramedics: bringing evidence into emergency medical personnel recruitment policy.

Introduction

Emergency medical services (EMSs) provide medical care for patients in life-threatening conditions in highly demanding, challenging, and interactive environments (1). In this context, emergency medical personnel (EMP) must have the ability to cope with emotionally challenging and stressful situations. Despite the many contextual variables that exist in emergency clinical practice (2), EMP have unique roles and responsibilities in dealing with stressful situations. Therefore, the personality traits of EMP have been the focus of a number of studies (3).

It would be advantageous to recognize personality traits that are congruent with emergency working conditions. Mitchell and Bray (4) indicated that a rescue person may score low in neuroticism and openness to experience but high in extraversion, low openness to experience, high conscientiousness, high agreeableness, and sensation seeking. Although a typical "rescue personality" has been reported in several studies (3), few studies have concentrated on the personality traits of EMP (5, 6). These traits are associated with job performance criteria, particularly conscientiousness (7). Individuals with high conscientiousness may show higher competency or more extrovert ones may have higher social interaction than others, but both traits are necessary for EMSs. On the contrary, neuroticism would play an unconstructive role in chaotic emergency circumstances. In addition, a debate has arisen from studies addressing the issue of whether personality traits are homogenous among EMP (8). Wagner et al. (3) concluded that there is little evidence for a distinct personality type that is reflective of emergency service workers as a whole. Therefore, this disparity must be addressed so that the personality traits of EMP can be fully identified.

Emergency medical personnel are typically involved in disasters and traumatic events that could contribute to the development of post-traumatic stress disorder (PTSD) (9). As PTSD and burnout are recognized as serious issues among EMP (10, 11), it is vital to identify the personality traits of EMP that would help them cope effectively with stress so that psychological health could be maintained. To this end, Chng and Eaddy (11) investigated the relationship between sensation seeking and burnout, while Sheikhbardsiri (10) evaluated the relationship between personality traits and PTSD among EMP. Thus, there is a strong rationale for obtaining comprehensive insight into personality traits that cause an individual to be susceptible to psychological disorders, particularly PTSD.

To summarize, the significant role of EMP in EMSs, their multidimensional role in a decidedly interactive context, and the considerable occurrence of psychological disorders among EMP make it necessary to systematically review the personality traits of this group of workers to identify a personality profile that makes an individual suitable for prehospital emergency practice.

Materials and Methods

A literature review was performed to identify the personality traits of EMP. A search retrieved potentially relevant articles in electronic databases, such as MEDLINE, SCOPUS, CINAHL, and PsychINFO. The databases were searched from their conception to March 1,2015, without any additional filters. The search terms used were "personality," "trait," "rescue," "emergency," "medical," "services," "personnel," "paramedic," and "technician." The procedures used in this review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (12). Articles about the personality traits of EMP were included if they evaluated the personality of paramedics or emergency medical technicians or if they identified a "rescue personality." Studies that represented gray literature, congress abstracts, reviews, case studies, and duplicate publications were excluded. Two researchers independently reviewed the titles and abstracts of all papers identified in the primary search results. Disagreements were discussed by the researchers to reach a consensus. Relevant articles found in the reference lists of the retrieved papers were also searched for (Figure 1). If necessary, the authors of the research articles were contacted to retrieve supplementary information. The final articles were reviewed by the authors. Data extraction involved the two authors' independent reviews of each article and was based on country, instrument type, participants, sample size, and the results. The methodological rigor of the studies was also assessed. The authors reviewed the extracted data together and agreed on the results of the extraction of data and quality of each article (Table 1).

Results

Of 398 articles that were found, 27 were included in the final sample; a total of 9,721 paramedics had participated in the selected studies. Seven studies had been conducted in the US, six in Australia, two in Germany, two in Slovakia, and one each in South Africa, Austria, Canada, Sweden, Hungary, Iran, Norway, Romania, China, and England. Nine studies used researcher-constructed questionnaires, and the remaining studies used standardized instruments (Table 1).

[FIGURE 1 OMITTED]

Big five personality and associated traits

Neuroticism: Traits related with neuroticism are being anxious, angry, emotional, worried, and insecure (7). EMP scored lower on neuroticism than the norm sample (5). Paramedics also scored significantly lower for neuroticism than other healthcare professionals (8). Among EMP, dispatchers had significantly higher scores than other groups for neuroticism, while ambulance drivers scored the lowest in this category (13). Furthermore, neuroticism was strongly related to the severity of stressors and to organizational conditions (14).

Extraversion: Traits related with extraversion are sociable, assertive, talkative, and active (7). EMP showed no differences in extraversion scores compared to the norm sample (5). Paramedics also scored significantly lower for extroversion than other healthcare professionals (8). Among paramedics, males were significantly less introverted than females (8), and it was possible to predict decision-making based on extraversion among male paramedics (6). The choice to join EMS was solely related to extraversion in comparison with firefighter jobs (15). Paramedic students scored lower for extraversion than other students in the university (16); high levels of anxiety and extraversion were negatively related to academic performance (17). Extraversion was also significantly related to the perceptions of post-traumatic growth (PTG) (18).

The sensation-seeking trait may also be associated with extraversion. EMP scored higher on risk and competition seeking than the norm sample (5, 12). Paramedics scored insignificantly lower on risk taking than other healthcare professionals (8). Paramedics who scored high on burnout also scored high on sensation seeking (19). Among firefighters, the preference for firefighting over EMS work was predicted by the characteristic of fearlessness (15).

Openness to experience: Traits related with openness to experience are being imaginative, cultured, curious, broad-minded, and artistically sensitive (7). EMP scored lower on openness than the norm sample (5). The review also indicated that there was no difference between paramedics and other healthcare professionals in terms of openness to experience (8). Ambulance worker professional groups scored lower on openness to experience than doctors (13). Among firefighters, individuals who preferred firefighting over EMS work were predicted by low scores for openness to experience (15). Perceptions of PTG were significantly related to openness to experience (18). Experiential avoidance related to lower scores for openness to experience was consistently negatively correlated with well-being among EMP (20).

Conscientiousness: Traits related with conscientiousness are being careful, thorough, responsible, and organized (7). EMP scored higher on conscientiousness than the norm sample (5, 21). Conscientiousness was significantly related to perceptions of PTG (18). Resiliency related positively to conscientiousness and negatively to neuroticism. Consequently, 50-70% of EMP could be characterized as resilient (8). Conscientiousness was due to the integration of emotional and regulatory invariability and lower mental arousal (22). Stress tolerance ranked highest among the 21 items in ambulance personnel's self-description measuring ambulance attendants' perceptions of personality (23). Higher resiliency scores were significantly associated with better general health and well-being (24). Participants meeting PTSD criteria also had significantly lower scores for resiliency (25).

Agreeableness: Traits related with agreeableness are being flexible, trusting, cooperative, forgiving, and tolerant (7). EMP had lower scores for agreeableness than the norm sample (5). Among firefighters, the preference for firefighting over EMS work was predicted by a low score for the characteristic of agreeableness (15). Agreeableness significantly related to perceptions of PTG (18). Altruism scores were also high among paramedics, the difference being significant only in comparison with doctors (8). Both paramedics and paramedic students had significantly low scores for empathy (26). However, female paramedic students were identified as being more empathetic than their male counterparts (27-29). In general, empathy levels either declined (27) or improved (28, 29, 30) as students progressed through their coursework programs. Paramedic students (in response to empathy for medical conditions) scored the lowest for substance abuse and the highest for intellectual disability (27). Honesty is one of the dimensions of the HEXACO (honesty-humility, emotionality, extraversion, agreeableness, conscientiousness, and openness to experience) personality model, and some of the characteristics categorized under honesty-humility are incorporated into the big five's agreeableness factor. Honesty was the most important characteristic reported by EMP (31). EMP are spiritual but not more so than the average civilian, and EMP with more active spiritual lives perceive themselves as happier (32). Although help is not a personality trait, helping behavior or prosocial behavior is also related to the big five traits, particularly to agreeableness. EMP reported that being able to help others was the most important and satisfying aspect of their work.

Discussion

Paramedics have been shown to score high for conscientiousness (5, 22). This means that they make every effort to be extremely thorough when administering EMSs (4). Life-threatening conditions require the attention of organized and responsible personnel, indicating that conscientiousness is a vital trait for paramedics. In addition, there is a significant difference in the key trait of conscientiousness between high- and low-level performance groups of dispatchers (13). Therefore, conscientiousness is recognized as an essential trait for EMP. However, the trait of conscientiousness may occasionally put paramedics at a disadvantage. Penterman et al. concluded that workers who score high on conscientiousness are sometimes inflexible in their responses during patient interactions, so the patient might quickly become irritated (21). It has also been reported that PTSD is significantly correlated with the personality trait of conscientiousness; however, this result requires further investigation (11).

It has also been shown that paramedics score high on sensation seeking (5, 12, 19). Due to the varied, new, complex, and intense situations that exist in the clinical practices of EMP, it would appear that the trait of sensation seeking is fitting in individuals who assume paramedic roles. Sensation seeking has been recognized as a common trait in rescue workers (4). Chng and Eaddy (11) showed a weak correlation between sensation seeking and burnout; however, Palmer and Spaid showed that, overall, burnout is not correlated with sensation seeking (19).

Paramedics had low scores for neuroticism (5, 8). As Mitchell and Bray (4) indicated, people involved in rescue work may benefit from a calm and measured attitude (low neuroticism). Emotional stability is vital for paramedics who are involved in life-threatening medical situations in daily clinical practice (5), where they are required to remain controlled in many emergency situations and feel secure. Low neuroticism may indicate that paramedics are using effective coping mechanisms in response to stressful situations (19). In addition, neuroticism is significantly correlated with PTSD in EMP (11). It should be noted that these traits are not homogenous for all EMP. In contrast, dispatchers scored higher in neuroticism. Niculita mentioned that this might be related to their inability to stabilize a caller's situation or to provide the necessary assistance (13). Therefore, it is vital to implement effective interventions to lessen the effects of PTSD, particularly among dispatchers (33). As PTSD is significantly associated with lower levels of resiliency (34) and as resiliency relates positively to conscientiousness and negatively to neuroticism (8), resiliency should be considered as a protective trait for EMP.

Paramedics scored lower in extraversion (8). Although being introverted may seem to prevent the engagement of paramedics in intense personal interactions, being sociable, talkative, and active have been reported as appropriate traits for paramedics and for all individuals involved in rescue operations and engaged in daily interaction and communication with people (4). Several studies have confirmed that extraversion is one of the personality traits negatively associated with burnout (35). In addition, a tendency to be more optimistic may result in extroverted paramedics experiencing more feelings of satisfaction with their work (36).

Paramedics have also shown lower scores in openness to experience and agreeableness (5, 8). Mitchell and Bray (4) indicated that high agreeableness and low openness are optimal personality traits for rescue workers. Empathetic, highly dedicated, and a strong need to rescue others are key traits of the role models of paramedics (8, 36). Klee and Renner (5) discussed the discrepancy between low agreeableness and empathetic attitude, which may be related to the construct validity of the personality scales. Paramedics did not show imaginative and independent personalities (5, 8). This trait may be instrumental in their ability to precisely follow routines and procedures. Thus, it may be assumed that paramedics are resistant to new experiences.

Personality traits are related to burnout (37). Chng and Eaddy (11) reported that there may be no relationship between sensation seeking and burnout among EMP in spite of the weak positive correlation, so sensation-seeking or extroversion traits may not protect EMP from burnout. However, Sheikhbardsiri (10) showed that conscientiousness and neuroticism were significantly correlated with the Mississippi combat-related PTSD scores, suggesting that these personality traits accelerate burnout. These findings have been confirmed by Alarcon et al. (37), who meta-analytically indicated that neuroticism, extraversion, and conscientiousness are related to burnout.

Emergency medical personnel personality traits are congruent with professional practice in accordance with contemporary factor models for personality. The personality traits of EMP suffer from limited evidence and require further investigation, particularly to elucidate the association of the identified traits with certain critical disorders, such as PTSD and burnout (38, 39). Our review is limited due to the absence of randomized clinical trials in the field of personality traits of EMP and their association with work performance and professional proficiency, so a more rigorous design method is recommended.

Conclusion

Paramedics score high in conscientiousness, sensation seeking, resiliency, and empathy, but low in extroversion, neuroticism, and agreeableness. While high conscientiousness and low neuroticism could be assumed to be protective traits against PTSD in EMP, certain personality traits, such as conscientiousness, that help paramedics provide patients with secure medical service, also put them at risk of burnout. Further investigations into the personality traits of paramedics' role models and performance indicators related to personality traits is required.

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

References

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Amir Mirhaghi [1], Maryam Mirhaghi [2], Atsushi Oshio [3], Saeid Sarabian [4]

[1] Department of Medical-Surgical Nursing, Mashhad University of Medical Sciences, Mashhad, Iran

[2] Department of Clinical Psychology, Shahrood Islamic Azad University, Shahrood, Iran

[3] Faculty of Letters, Arts, and Sciences, Waseda University, Tokyo, Japan

[4] Department of Clinical Psychology, Payame Noor University, Mashhad, Iran

Correspondence to: Amir Mirhaghi e-mail: mirhaghi@mail.com

Received: 01.07.2016 Accepted: 18.07.2016

DOI: 10.5152/eajem.2016.80299
Table 1. Summary of findings extracted from the review literature on
the personality profiles of paramedics

Study                  Participants   Instrument

Backus et al. (32)     125            Questionnaire about their
                                      beliefs and behaviors
                                      regarding their spirituality

Grevin (26)            225            MMPI-2 PK Scale

Palmer and Spaid       91             Standardized instruments
(19)

Chng and Eaddy (11)    425            Arnett's Inventory of
                                      Sensation Seeking and
                                      Revicki's Work-Related Strain
                                      Inventory

Reich (38)             31             Adjective checklist and
                                      23-item social identities
                                      questionnaire

Brown et al. (39)      361            46-item core survey and a
                                      16-item survey

Regehr et al. (34)     86             The Bell Object Relations and
                                      Reality Testing Inventory
                                      (BORRTI)

Fannin & Dabbs         195            Questionnaires
(2003) (15)

Jonsson and Segesten   362            Professional Self-Description
(23)                                  Form (PSDF)

Kilner (31)            34             Questionnaire

Louria (17)            53             16 Personality Factor
                                      Questionnaire (the 16 PF)

Shakespeare-Finch et   526            Questionnaire
al. (18)

Mitmansgruber et al.   239            Meta-emotion scale, Mindful
(20)                                  attention and awareness scale,
                                      positive affectivity and
                                      negative affectivity scale

Sterud et al. (14)     1180           Basic Character Inventory

Pajonk et al. (8)      245            Hamburg Personality Inventory
                                      (HPA)

Pilarik and Sarmany-   92             The Iowa Gambling Task, EQTM
Schuller (6)                          map, Stroop test,
                                      Rational-Experiential
                                      Inventory, NEO-FFI
                                      questionnaire

Abedi et al. (16)      492            The NEO-Five-Factor Inventory
                                      (NEO-FFI)

Gayton and Lovell      219            The 10-item Connor-Davidson
(24)                                  Resilience Scale

Williams et al. (27)   783            Medical Condition Regard Scale
                                      (MCRS)

Williams et al. (28)   783            Jefferson Scale of Physician
                                      Empathy-Health Profession
                                      Students

Jurisova and           134            Melbourne Decision-Making
Sarmany-Schuller                      Questionnaire, MDMQ,
(22)                                  Questionnaire SPARO

Klee and Renner (5)    173            Critical Incident Stress
                                      Debriefing, Hamburg
                                      Personality Inventory

Niculita (13)          458            The Big Five[C]plus Personality
                                      Inventory, Sensation Seeking
                                      Scale

Fjeldheim et al.       131            Connor-Davidson Resilience
(25)                                  Scale (CD-RISC)

Sheikhbardsiri (10)    180            The NEO Five-Factor Inventory
                                      and the Mississippi
                                      combat-related PTSD scale

Williams et al. (29)   1719           Jefferson Scale of Physician
                                      Empathy--Health Profession
                                      Students' version (JSPE-HPS)

Williams et al. (30)   554            Jefferson Scale of Physician
                                      Empathy--Health Profession
                                      Students' version (JSPE-HPS)

Study                  Results

Backus et al. (32)     EMP are interested to talk about their
                       spiritual lives. Those EMTs with more active
                       spiritual lives perceive themselves as
                       happier.

Grevin (26)            Both paramedics and paramedic students had
                       significantly low scores on empathy.

Palmer and Spaid       Burnout did not correlate with the overall
(19)                   sensationseeking scale.

Chng and Eaddy (11)    EMP had significantly higher sensation-
                       seeking scores than the general public, but
                       this dimension alone does not protect them
                       from the effects of burnout.

Reich (38)             EMT now/real me was significantly correlated
                       with activity. EMT future/real me and EMT
                       future/ought me were both significantly
                       correlated with commitment.

Brown et al. (39)      Being able to help others was the most
                       important and satisfying aspect of work life
                       of EMP.

Regehr et al. (34)     EMP with personality patterns characterized
                       by suspiciousness, hostility, and isolation
                       and who had a tendency toward demanding,
                       controlling, and manipulative behavior in
                       relationships were more likely to have taken
                       a mental health stress leave.

Fannin & Dabbs         EMS performance was predicted by
(2003) (15)            extraversion. EMS performance was related to
                       an interaction of testosterone with
                       conscientiousness.

Jonsson and Segesten   Stress tolerance, consideration, and
(23)                   flexibility had the highest rank among the 21
                       self-description items named by ambulance
                       personnel.

Kilner (31)            Honesty, patient-centered approach and having
                       caring, empathic and values life from
                       technician's viewpoint.

Louria (17)            Five factors were found to be significant in
                       relation to academic achievement on this
                       course. These included abstract, verbal
                       reasoning, levels of anxiety, levels of
                       extraversion, work methods, and year level of
                       study.

Shakespeare-Finch et   Correlations revealed that extraversion,
al. (18)               openness, agreeableness, conscientiousness,
                       and coping levels significantly relate to
                       perceptions of PTG.

Mitmansgruber et al.   Meta-emotions would allow for a meaningful
(20)                   differentiation of processes in emotion
                       regulation. Experiential avoidance is
                       consistently negatively correlated with well-
                       being.

Sterud et al. (14)     Neuroticism was related to higher severity
                       scores in all stressor dimensions except for
                       time pressure. Neuroticism was related to
                       both severity and frequency of lack of sup
                       port from co-workers and leaders.

Pajonk et al. (8)      Results revealed differences for nervousness,
                       extraversion, control, and altruism but not
                       for openness and risk taking.

Pilarik and Sarmany-   In men, it was possible to predict
Schuller (6)           appropriate decisionmaking based on emotional
                       stability, extraversion, and quick reactions.
                       Appropriate decision-making of female
                       paramedics could be predicted based on two
                       zones of emotional intelligence (low
                       emotional awareness and positive current
                       conditions) and on quick reactions in the
                       Stroop test.

Abedi et al. (16)      Paramedical students were more introverted
                       than others.

Gayton and Lovell      These results showed that higher resiliency
(24)                   was significantly associated with better
                       general health and well-being.

Williams et al. (27)   Females had higher mean scores than males on
                       each medical condition, supporting the
                       multitude of empathy studies in healthcare
                       students, where females were identified as
                       being more empathetic than their male
                       counterparts.

Williams et al. (28)   Females had greater mean empathy scores than
                       males: 108.69 vs 103.58 (p=0.042).

Jurisova and           Significant relationships between components
Sarmany-Schuller       and factors of mental integration (emotional
(22)                   and regulatory invariability, lower mental
                       arousal) were found. Their integration forms
                       a "calm, mentally stable and resilient
                       personality type."

Klee and Renner (5)    EMS personnel scored lower on neuroticism and
                       openness but higher on conscientiousness and
                       risk and competition seeking than a norm
                       sample. EMS personnel showed lower scores for
                       agreeableness and no differences for
                       extraversion. EMS volunteers did not differ
                       from EMS professionals regarding personality,
                       except for the degree of extraversion.

Niculita (13)          The results revealed a series of significant
                       personality differences among professional
                       groups of ambulance workers. The high-level
                       performance dispatchers group showed
                       significant differences from the low-level
                       performance group of the same category
                       regarding their scores to the following
                       personality scales and subscales:
                       conscientiousness, self-efficacy, and
                       achievement striving.

Fjeldheim et al.       Participants meeting PTSD criteria also had
(25)                   significantly lower levels of resiliency and
                       social support. Participants meeting criteria
                       for PTSD had significantly higher rates of
                       depression, perceived stress, and physical
                       health symptoms and significantly lower rates
                       of resiliency and social support.

Sheikhbardsiri (10)    PTSD of EMP was significantly correlated with
                       personality traits of conscientiousness and
                       neuroticism.

Williams et al. (29)   Empathy did not decline during course
                       progression with third-year students
                       recording the highest mean empathy score
                       across all 3 years.

Williams et al. (30)   Overall, self-reported empathetic regard for
                       each medical condition included intellectual
                       disability, substance abuse, attempted
                       suicide, and acute mental illness. For
                       students as a whole, mean scores generally
                       improved over their course as they progressed
                       through their degree. This study found that
                       compared to males, females generally have a
                       higher regard for patients presenting with
                       intellectual disability, substance abuse, and
                       attempted suicide.
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Title Annotation:Systematic Review
Author:Mirhaghi, Amir; Mirhaghi, Maryam; Oshio, Atsushi; Sarabian, Saeid
Publication:Eurasian Journal of Emergency Medicine
Date:Sep 1, 2016
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