Iran Occupational Health

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Background and aims: Pre-hospital emergency care technicians are faced with a high level of physical and mental stress because they must quickly attend emergency situations, and this high level of stress can lead to occupational stress in them. Occupational stress is the result of an interaction between job conditions and personal factors, when the demands of the workplace and the related pressures are higher than the degree tolerated by the individual. Research shows that prolonged and continuous stress in the workplace can result in reduced productivity, decreased job satisfaction, poorer quality of service provision to patients, fewer accurate and timely decisions, a sense of job-related incompetence, occupational fatigue, a higher degree of absenteeism, and finally the occupational burnout syndrome. If occupational burnout is not identified and an effective solution is not proposed to reduce or prevent it, the physical and mental health of the employees will be threatened, and their performance efficiency and quality will suffer. Having a skillful and efficient human force is an important factor contributing to the efficiency of organizations; therefore, it is necessary to implement personal interventions to enhance the capacity of the employees in the face of stress, and maintain and promote their mental health. One such intervention which may help mitigate occupational stress is the use of positive psychology. In positive psychology, one’s higher focus on the positive aspects of events and less focus on negative aspects create a positive feeling, promote effective relationships with others, contribute to rational decisions, improve one’s resilience in the face of problems, and help one resolve life challenges and better manage problems. A gratitude program is a positive psychology skill which serves as a mental health indicator and complements psychotherapy and cognitive therapy interventions. Gratitude is not compatible with negative feelings and emotions such as stress, and even protects one from the impact of mental distress. It empowers people in fighting stress and promotes their general positive attitude by improving mental, spiritual, and physical well-being. It is evident that emergency care technicians experience high levels of stress and occupational burnout as a result of the stressful nature of their job. Thus, it is highly important to study the mental health of these technicians. The present study examined the effect of a gratitude program on the stress and occupational burnout of pre-hospital emergency care technicians.
Methods: This was a randomized two-group ad three-phase field trial with a pretest-posttest (immediately after intervention) design and one-month follow-up. Eighty pre-hospital emergency care technicians in the south of Isfahan Province, Iran, were randomly selected. After explaining the study to the participants and receiving their written informed consent for participation, they were randomly allocated to the experimental and control groups based on the inclusion criteria. The demographic information form, the Occupational Stress in Emergency Technicians Questionnaire, and the Maslach Burnout Inventory were completed by both groups in the introductory session and before implementing the intervention. The demographic information form examined the participants’ age, marital status, job experience, working hours, level of education, type of employment, and type of the emergency base. The occupational stress questionnaire was developed and standardized by Danesh. It comprised 46 items examining stress in four dimensions of physical, occupational, group-related, and organizational. The reliability of this questionnaire was examined in the present study by checking its internal consistency, and the Cronbach's alpha of 0.86 was obtained. The Maslach Burnout Inventory consisted of 22 items which assessed the three dimensions of occupational burnout: emotional exhaustion, lack of personal accomplishment, and depersonalization. Maslach and Jackson reported the internal consistency coefficient of 9.0, 0.79, and 0.71 for emotional exhaustion, depersonalization, and personal accomplishment, respectively. The reliability and validity of this questionnaire were confirmed by numerous studies in Iran, and Cronbach’s alpha of 0.75-0.87 was reported for it, indicating its reliability. The intervention comprised six sessions of in-person gratitude program as a positive coping technique in stressful and difficult situations, developed based on the models of verbal gratitude (Emmons & McCullough, 2003), behavioral gratitude (Tsang, 2002), and practical gratitude (Seligman, 2005), and approved by the Department of Psychiatric Nursing,  School of Nursing and Midwifery, Isfahan University of Medical Sciences. The educational content consisted of writing a letter of gratitude to significant people in one's life, consciously searching for gratitude in daily life, recalling memories of gratitude by people and the organization during one's work life, increasing attention to the smallest positive events during missions despite a high level of stress and recording them. Next, the program was followed for four weeks online by using the Telegram app. For the experimental group, five in-person sessions of gratitude were held at the Accidents and Emergencies Educational Center in the south of Isfahan Province. At the end of the fifth session, the participants joined a Telegram channel and were requested to record the positive aspects which merited gratitude encountered in their missions for four weeks (twice a week). The person in charge of education at the center reminded the participants of sending their messages to the Telegram group once before the shift was started and once at the time of shift change. After four weeks of online program, the sixth session was held at the center, in which the content provided throughout the program was summarized, and the messages sent to the Telegram group were examined in terms of their positive and negative load. The participants were then asked to fill in the same questionnaires once more. To eliminate the cohort effect of the intervention group, the control group also received two sessions in which general topics related to the missions and the importance of implementing mental health interventions for the personnel were discussed. The control group joined another Telegram group and their requested to record the events related to their missions for four weeks (twice a week). At the end of this program, the control group also filled in the questionnaires, and their messages were examined in terms of negative and positive loads. One month later, all the participants in the experimental and control groups completed the questionnaires for a third time without receiving any additional intervention. The questionnaires were distributed and collected in all three phases by the person in charge of education at the center. The data were inputted in SPSS 18 and analyzed by using t-test and ANOVA.
Results: The highest frequency in both groups belonged to married people who worked in urban bases on a 24-hour basis. In terms of level of education and type of employment, the highest frequency belonged to those with a bachelor's degree and full employment (experimental group), and an associate degree and contractual employment (control group). Results of the t-test indicated that the mean scores of the dimensions of occupational stress and burnout did not significantly differ before the intervention between the two groups (p>0.05). However, this difference was significant immediately after and one month after the intervention (p<0.001), demonstrating the effect of the gratitude program on the dimensions of occupational stress and burnout in the experimental group.  One-way ANOVA showed that, in the experimental group, the mean difference in the scores of the dimensions of occupational stress and burnout before, immediately after, and one month after the intervention was significant in all the dimensions of occupational stress, except for the group-related dimensions (p<0.05).  In other words, the intervention affected the physical, occupational, and organizational dimensions of occupational stress. Findings also showed that gratitude was effective only on the emotional exhaustion dimension of occupational burnout (p<0.05).
Conclusion: Based on the findings, implementation of the gratitude program reduces occupational stress and also affects emotional exhaustion which is a dimension of occupational burnout. Based on the nature of the emergency care technicians’ job and the inadequate time they have to spend on mental health programs, the implementation of such programs over messaging services such as Telegram is cost-effective and practical in a short period. It can also help these technicians overcome occupational stress in the first stages, preventing it from progressing to more advanced levels which lead to occupational stress. The effect of interventions is stronger in the first stages of a problem than the final and progressed stages. This must be kept in mind when trying to prevent occupational burnout which has negative effects on organizational productivity and personal relations. It is recommended that such programs be implemented to maintain and promote the mental health of pre-hospital emergency care technicians.

Keywords: Gratitude program, Job stress, Burnout, Pre hospital technicians

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