Experiential/Motivational Experiential/Motivational Intervention:Intervention:

Changing Beliefs & Behaviors Changing Beliefs & Behaviors in Stress Managementin Stress Management

AAHE Presentation

Tampa, Florida

April 3, 2009

Session GoalsSession Goals

Demonstrate that a one-time intervention can make a difference

Outline the COMPLEX model process including its theoretical basis

Demonstrate the COMPLEX model as an effective method of experiential learning

Session ObjectivesSession Objectives

Attendees will gain a greater appreciation for:The significance of critical incident stress

experienced by EMS providersThe importance of pre-incident preparation

for learning ways of proactive coping

BackgroundBackground

Using the COMPLEX Model to Change Beliefs Regarding Proactive Coping

Behaviors in Emergency Medical Service Trainees

by

Dale Maughan RN, EMT-P, PhD

Submission for publication pending.

Why?Why?

“In over 25 years in EMS, the thing that is painfully obvious to me is the fact that we make a great effort to protect ourselves from infectious diseases, blood spatters, and hazardous materials. All the while, the most insidious and widespread problem out there for EMS practitioners, their families, and friends is the inability to leave EMS at the station. This eventually gets to the point of sacrificing close and meaningful relationships in our zeal for professional gratification. You need to make sure to take care of yourself while you are taking care of others.”

Paul A.WerfelNREMT-P, Director, Paramedic ProgramAssistant Professor of Clinical Emergency Medicine,State University of New York at Stony Brook

Emergency Medical Service Emergency Medical Service StressStress

Comparison High in emergency response (Boudreaux et al., 1997; Crabbe et al., 2004; Owen, 1997; Van Der Ploeg & Kleber, 2003; Weiss et al., 1995)

Higher than other health-related occupations (Al-Nasar & Everly, 1999; Marmar et al., 1999; Hammer et al., 1986)

Magnitude Exposure daily (Al-Nasar & Everly, 1999; Neale, 1991; Owen, 1997)

Stressors Loss of control

Shift work/lack of sleep

Significant injury/death of a coworker or child

Perceived or actual physical threat to self

Domestic violence

Dismembered body

Multiple casualty motor vehicle crash

Vicarious traumatization

Consequences Post Traumatic Stress Disorder

Acute stress disorder

Secondary traumatic stress disorder

Somatic disorders

Strained relationships

Burnout

Emergency Medical Service Emergency Medical Service StressStress

Personality EMS personality – controversial (Grevin, 1996; Mitchell & Everly, 1994;Wagner, 2005)

No clear evidence of protective characteristics (Moran & Britton, 1994)

Training National Standard Curricula – minimal, didactic (DOT, 1996)

Initial training time limited – max 120 hours (DOT, 1996)

Prevention Evidence of the need (Bennett et al., 2005; Jonsson & Segesten, 2004; Harbert, 2000; Mitchell & Everly, 1994; Oster & Doyle, 2000; Regehr et al.)

Documentation of efforts limited (EMS Agenda for the Future, 1996)

Treatment Critical incident stress debriefing (Mitchell & Everly, 1994, 2000)

Research Prevention – severely lacking (National EMS Agenda for Research, 2001)

Proposed ModelProposed Model

Beliefs

Goals

Values

Attitudes

Perceptions

Critical Incident

Primary Appraisal

Secondary Appraisal

Coping Behaviors

Consequences Physical Mental Emotional Spiritual Social

Pre-Incident Preparation Realistic Expectation Development Wellness Education Proactive Coping Behavior Training

Coping BehaviorsCoping BehaviorsBreathing Simplest form of stress management (Luskin in Evans, 2005)

Controlling the breath alters “fight-or-flight” response (Gordon in Evans, 2005)

Attributed to arousal reduction (Chapell, 1994)

More adaptive responding to negative stimuli (Arch & Craske, 2006)

Positive Self-Talk Primary cognitive mediator of stress (Chapell, 1994)

Must be believable to client, provides support, self-attributions for gain in anxiety control (Meichenbaum & Deffenbacher, 1988)

Can tell the body no need for arousal (McKay, Davis, & Fanning, 1981)

Cognitive Restructuring

May enable workers to tolerate stressful work environments (DOVA & DOD, 2004)

Evaluate validity/viability of thoughts/beliefs, elicits/evaluates predictions, explores alternative explanations, alters absolutist, catastrophic thinking styles

(Meichenbaum & Deffenbacher, 1988)

Process by which focus is on good in what is happening, discover opportunities for growth and how actions benefit others (Folkman & Moskowitz, 2000)

Aside from problem solving, the most powerful crisis intervention (Pennebaker, 1999)

Opportunity to learn from experience, focus on positive (Regehr, Goldberg & Hughes, 2002)

Results/RecommendationsResults/Recommendations

The COMPLEX model was effective in changing outcome expectancy and self-efficacy beliefs regarding the use of select proactive coping behaviors in EMS trainees.

The next step is to evaluate actual adoption of behaviors.

COMPLEX ModelCOMPLEX Model

A model for experiential learningAuthors:

• Gary D. Ellis• Catherine Morris• Eric P. Trunnell

World Leisure & Recreation, V. 37, 1995

COMPLEX ModelCOMPLEX Model

Create GoalsOrientMotivateParticipationLog-OffEdifyExamine

COMPLEX ModelCOMPLEX Model

Theoretical Basis• Arousal ( Berlynne, 1960; Ellis, 1873; Eysenck, 1982;

Festinger, 1957)

• Expectancy Valence (Rotter, 1975)

• Self-Efficacy (Bandura, 1986)

• Attribution (Abramson, Seligman & Teasdale, 1978; Heider, 1958; Russell, 1992)

COMPLEX ModelCOMPLEX Model

Create Goals Orient – Arousal Motivate – Expectancy-Valence, Self-Efficacy Participation – Self-Efficacy Log-Off Edify - Attribution Examine

COMPLEX ModelCOMPLEX Model

Arousal

People strive to maintain a level of alertness/activity/interest (arousal) that is appropriate to their circumstance.

COMPLEX ModelCOMPLEX Model

Self-Efficacy

Decisions to participate or not are dependent on one’s efficacy and outcome expectations.• Performance• Vicarious experience• Verbal persuasion• Arousal

COMPLEX ModelCOMPLEX Model

Expectancy-Valence

Decisions to participate or not are dependent on one’s desire for specific benefits and how much value are placed on them.

COMPLEX ModelCOMPLEX Model

Attribution

Causes identified for outcomes• Internal vs. External• Stable vs. Unstable• Global vs. Specific

COMPLEX Model BlueprintCOMPLEX Model BlueprintStrategy Theory/Content/Messages

Create Goals Purpose of the educational experience

Orient Arousal

Motivate Expectancy Valence

Expectancy: If I concentrate on my breathing, I can be in control of my stress response.

Valence: It is important for me to be able to manage stressful situations.

Self-Efficacy

Performance: I watched you in total control of your breathing during our last session.

Vicarious: Watch how Bob is able to focus on his breathing when distracted.

Verbal persuasion: I know you will be able to do this when you are in a stressful situation.

Participation Self-Efficacy

Performance: You are breathing evenly, demonstrating your ability to be in control.

Vicarious: I can see you are able to concentrate on each breath like Ann is.

Verbal persuasion: I bet you can do this regardless of the intensity of the stress you are experiencing.

Attribution

Internal: You are in total control of your breathing.

Stable: You can do this again.

Global: I believe you can do this when …….

Log-Off Close the experience

Edify Attribution

Reflection: What did you experience?

Generalization: Have you experienced something similar before?

Examine Application: In what situations can you apply what you have learned in your own life? How can it be applied in other situations where the need to focus or be mindful is critical?

COMPLEX ModelCOMPLEX Model

Key Components• Experience• Ordered messages• Flexibility• Processing

Reflection Generalization Application

Questions?Questions?