Investigating Occupational Stress of Disaster and Emergency Medical Management Center 115 and the Role of Demographic Variables in Kermanshah, Iran CURRENT STATUS: POSTED

Background: The first and one of the most important chains of providing care to patients is prehospital emergency medical services. Personnel employed in this sector are at risk of occupational stress due to the nature of their job which can affect their health and quality of services provided to patients. Therefore, the present study was conducted to investigate the occupational stress of the personnel of disaster and emergency medical management center 115 and the role of demographic variables in 2019. Methods: This is a descriptive-analytical study. 200 medical emergency personnel of Kermanshah province were selected through stratified sampling and according to inclusion criteria. A two-part questionnaire including demographic information and HSE standard questionnaire were used for collecting data. Finally, descriptive and inferential statistics (t-test and one-way ANOVA) were used for data analysis. Significance level was considered P<0.05. Results: The mean score of total occupational stress was 3.41±0.26. The highest and the lowest stress levels related to the role dimensions was calculated (4.34±0.35) and changes (2.72±0.86). There was a significant relationship between stress level with age, marital status, educational level, type of base of work place and hours of work per month, while there was no relationship between type of employment and work experience with stress level. Conclusion: Emergency medical personnel experience a high level of occupational stress. Senior managers can use the results of similar studies to think measures to reduce the experience of employees' stress.

cope effectively with it or support resources are scare, stress is considered a negative phenomenon that can cause physical diseases and mental disorders [2]. One of the most important sources of stress in any person's life is his/her job, and today, occupational stress has become a common and costly issue in the workplace that the United Nations has called it the twentieth-century disease. In recent years, the World Health Organization (WHO) has declared it a widespread problem [3].
Occupational stress is a type of emotional, cognitive, behavioral, and psychological response to harmful aspects of work and the work environment [4]. In general, occupational stress can be considered a response to stresses caused by work environment and it is occurred when expectations are higher than his/her abilities and authorities [5].
Numerous studies have shown the role of occupational stress in occurring disease symptoms, high labor displacement, and early retirement of individuals [6]. The Health and Safety Executive has predicted over 13.5 million working days and more than £4 billion losses annually due to the damages from occupational stresses during 2007-2009 [7]. Occupational stress is a situation that results from the interaction between individuals and jobs and its certain aspect is the changes occurring within individuals and forcing them to deviate from their normal way of action [8].
In this regard, several organizations have been founded to protect people's health, and one of these organizations is the Disaster and Emergency Medical Management Center which is responsible for providing clinical care to patients in pre-hospital medical emergency and transferring to medical centers if necessary [9]. The center is considered one of the main pillars of health care in all countries of the world and the most important goal of this system is to provide satisfactory services in the shortest possible time and in accordance with the modern scientific standards of the world [10].
Emergency medical services units are stressful environments and high pressure, sensitivity of seconds, extraordinary stress, timely diagnosis, expectations of companions and the importance of protecting patients' lives distinguish these sections from other sections [11]. The emergency medical services system is a part of a chain system in care of patients that continues from the time of the disaster to the rehabilitation and discharge of the patient [12]. The personnel employed in this section are as the first individuals to respond to patients in emergency medical situations [13]. This section provides the conditions in creating stress for the personnel employed in this sector due to time constraints in performing affairs, critical status of patient, expectations of companions, openness of the environment, fear of inadequacy in rescuing a dying patient, decision-making power in critical situations and factors related to manpower [14]. In other words, the physical, mental, and intellectual stressors cause the emergency medical technicians to be exposed at high risk, such as accidents, errors, and other injuries to persons (6). The clear examples of symptoms of occupational stress include insomnia, distraction, anxiety, absenteeism, depression, fatigue, excessive frustration, family problems, and physical problems such as heart disease, migraines, headaches, indigestion, and disc herniation between the lumbar vertebrae [15]. Increasing working hours causes the increase of conflict in occupational and family tasks which can lead to occupational stress [15]. The rotating nature of work shifts of emergency medical technicians gives little opportunity to adapt to sleep patterns that can lead to the disruption in mental health [16]. So that the effects of day and night shifts can be fatigue, sleep disorder, gastrointestinal disorders and poor performance [17].
In domestic studies, Sharifi et al. in their study in Kerman concluded that about half of emergency medical personnel experienced moderate occupational stress. There was a significant relationship between occupational stress with educational level and employment status, while age and marital status didn't have any relationship with stress [18]. The results of Dadashzadeh et al. study in urban and road bases and pre-hospital emergency medical services in East Azarbaijan province showed that the most important factor of stress load is occupational environmental factors and factors related to patient. There was also a significant relationship between the amount of stress load with the number of missions, educational degree, and type of base and employment status [19]. Seyed Javadi et al. in a study conducted on employees in 115 provinces of Ardabil stated that there was a significant correlation between age and occupational stress but there was no relationship between stress and marital status, educational level, type of base of work place and working hours per week [20].
In foreign studies, the results of a study in the UK showed that emergency medical technicians had the highest rank in terms of physical stress, the second rank in terms of dissatisfaction and the fourth rank in terms of mental health compering to the other 25 jobs [21]. The results of a study in Turkey showed that all the stressful and negative conditions in the pre-hospital emergency medical services lead to physical and psychological fatigue of the personnel and eventually lead to the development of burnout [22]. Leszczynski et al. showed that physicians and nurses in the emergency medical services department suffered more burnout compared to emergency medical personnel. They stated that emergency medical service personnel experienced the least amount of burnout compared to their colleagues [23]. Yuwanich et al. in Thailand announced that nurses of emergency medical services department are more at risk of occupational stress compared to nurses in other departments and less work experience is related to the stress [15].
In spite of the studies conducted, reviewing different backgrounds indicates that no study has been

Study design
This cross-sectional descriptive-analytical study was conducted from May to September of 2019. 200 male technicians employed in Emergency Medical Centers affiliated to Kermanshah University of Medical Sciences were selected using calculation formula of Cochran sample size (95% confidence level and 5% error) by stratified random sampling method appropriate with the population size. In this study 85 urban base personnel and 115 personnel of emergency medical road bases of 115 entered the study.
The ethical principles in conducting this study included approving the project at the respectful research council of Kermanshah University of Medical Sciences and taking a sampling license.
Researchers based on the personnel list, individuals and road specified the study criteria. The research project was approved by the Research Ethics Committee of Kermanshah University of Medical Sciences and informed consent was obtained from all study units. In order to prevent fatigue of the samples, they were asked to fill the questionnaires at home. The time required to complete each questionnaire was 15-20 minutes and data were collected within 9 weeks. Inclusion criteria was: 1-Being employed in pre-hospital emergency medical ambulance as one of the technical categories (rescuer, basic, middle and senior technician) (technicians employed in office and communication center were not considered. 2-The main job of the technician is to work in an ambulance 115 (not as overtime from other units and employment in low volume) 3-having work experience of more than six months in an emergency medical services 115 with a diploma degree and above. Unwillingness to participate in the study and incomplete completion of the questionnaires were considered as exclusion criteria. All research samples were explained that participation in this study was optional and all information is without name and confidential.
The questionnaire was given to 8 faculty members of nursing, psychology and emergency medicine and 6 emergency medical personnel to the face and content validity of the tool to be determined.

Tools
Data were collected using a two-part questionnaire. The first part was related to the demographic variables included: age, marital status, education level, field of education, work experience, High score from this questionnaire indicate less occupational stress [13]. The occupational stress questionnaire (HSE) was valid and reliable in the study by Azad Marzabadi et al. that its reliability was obtained 78% based on Cronbach's alpha coefficient [24]. Its internal consistency was 89% based on Cronbach's alpha coefficient.

Data Analysis
Descriptive (frequency, percentage, mean and standard deviation) and inferential statistics (ANOVA and independent t-test) and SPSS statistical software version 23.0 were employed. The significance level was set at p<0.05.

Ethical approval
Ethical approval was obtained from the Ethical Review Committee of KUMS. The purpose of the study was explained to all participants. Written informed consent was obtained from all participants, and they were assured of anonymity and confidentiality.

Results
In this study, the sample size was 200 emergency medical personnel in Kermanshah province, all of them were male. Therefore, the gender factor in this study was excluded. The results showed that the mean and standard deviation of age of participants was 30.14-5.96 years and more than half of the participants (58%) were in the age range of 20-30 years. 57% of them were married, and the rest were single. Most of individuals (80%) had emergency medical degree and almost all of them (98%) had associate degree (48.5%) or bachelor's degree (49.5%). Almost half of the individuals (47.5%) had less than 5 years of work experience and 35.5% were working on the majority of the project. In terms of type of base of work place, 42.5% of individuals were in urban base and 57.5% were in road base. More than half of them (58%) worked between 200 and 250 hours per month (Table 1). Mean and standard deviation of total score of occupational stress was 3.41±0. 26. The highest and the lowest level of occupational stress were related to role dimensions (4.34±0.35) and changes (2.72±0.86) ( Table 2). The mean total score of occupational stress in single individuals (3.48±0.29) was higher than married individuals (3.35±0.23) and independent t-test showed a significant difference (P=0.001). The results of this test showed that the mean total score of occupational stress in individuals employed in urban base (3.49±0.24) was significantly higher than those employed in road base (3.34±0.26) (P=0.000) ( Table 3). The mean score of stress in the dimensions of demand, control and change showed a significant relationship with the type of base of work place (P<0.05), which means that the mean score in all these dimensions in employees employed in urban bases was more than road bases ( Table 4). The result of ANOVA test showed that the mean total score of occupational stress has been decreased significantly by increasing age (P=0.000). ANOVA test showed a significant relationship between job stress with educational level and field of education (P=0.000), so that individuals with master's degree had higher occupational stress score (3.60±0.07) and individuals with emergency medical degree had a lower score (3.37±0.26) compared to other grades and fields. On the other hand, the results of this test showed that there is a significant relationship between occupational stress score and working hours per month (P=0.000), so that individuals with the lowest working hours (less than 150 hours per month) had higher occupational stress score (3.60±0.23). However, there was no significant relationship between work experience (P=0.092) and type of employment (P=0.241) with occupational stress score (Table 3).    arrival and in-service by senior executives to clarify the problem and reduce occupational stress is helpful. Also, another main cause of occupational stress in this study was the demand dimension (overwork, long hours, lack of rest and fast working), so senior executives can take measures such as providing sufficient force, compulsion to use paid leave and so on can reduce occupational stress of employees. On the other hand, the dimension of changes is related to the "way of organizing and changing the forces of the organization", so it seems that in the present study, there is a good relationship between managers and employees regarding inter-organizational changes.
The results showed that younger people had experienced more occupational stress (P=0.000). It should be noted that the sample population was young (more than half of the participants were in the age range of 20 to 30 years). Similarly, Moti et al. reported that as technicians' age increases to 40 to 45 years, their stress level is decreased [14]. It is natural that as the age and work experience increases, occupational stress decreases, in fact, increasing age to a certain level can have a protective role against stressors. D'Ettorre et al. stated that age had a significant relationship with occupational stress of nurses in emergency medical department [8].
However, Seyed Javadi et al. found contrast results in their study; as age increased, occupational stress increased in personnel employed in 115 [20]. Bardhan et al. considered age in relation with occupational stress, so that they announced that age over 40 is a risk factor for higher occupational stress among emergency medical nurses [27]. The researchers justified the results of their research so that by increasing age, the power of compatibility of individuals and coping with stressful work conditions is decreased, and it is natural that the occupational stress to be increased. In the present study, an increase was observed in stress in the age range of more than 50 years.
According to the present study, single people had more occupational stress than married people (P=0.001). Similarly, Shareynia et al. reported that stress was higher among single nurses [4].
However, the study by Seyed Javadi et al. showed that there is no relationship between occupational stress of emergency medical technicians and marital status [20]. And, in contrast, Mahboubi et al.
announced that married people has more stress among emergency medical personnel [28]. The results of recent research can be justified by the fact that single people have higher expectations from the family and the workplace which can increase hours and workload and thus increase occupational stress.
Educational level had a significant relationship with the level of occupational stress experienced by individuals (P=0.001). Only two percent of the participants in the study were postgraduate students who had experienced more occupational stress than others. Namdari et al. showed that as the level of education increased, the occupational stress of personnel employed in 115 increased and the tendency to continue service decreased which is in line with the present study [10]. By increasing education level as knowledge and skill is increased and the quality of service is expected to improve, because expectations from people are higher and often are in more difficult situations and more specialized work is done, therefore, occupational stress is increased. Moti et al. in their study concluded that technicians with a bachelor's degree had experienced more occupational stress compared to other people (with a diploma and associate degree), which is consistent with the present study, but ultimately there was no significant relationship between educational level and stressors [14]. People in stressful situations that require quick decision-making, regardless of their level of education, may not be able to act effectively and experience high stress.
There was a significant relationship between occupational stress and education degree (P=0.000). In this study, the majority of participants (80%) had emergency medical degree that had less stress compared to other fields of study (nursing, anesthesiology, and practical nurse). Similarly, Namdari et al. showed that occupational stress had a significant relationship with education field of emergency medical employees [10]. This issue can be justified so that emergency medical graduates have passed academic specialized training for providing service in pre-hospital conditions, thus they experience less occupational stress compared to other courses trained for hospital conditions. This issue shows the need to employ more relevant people in emergency medical centers. It seems natural that selecting people with a job-related degree will reduce workplace stress.
The results of this study showed that people in urban bases generally had more occupational stress compared to people in road bases (P=0.000). Similarly, Modi et al. and Namdar iet al. stated that the stress in employees of urban base was higher than road base [10,14]. In the present study, the number of missions per day, the type of missions, and other factors associated with the type of base of work has not been investigated. Therefore, in case of further studies and confirmation of the relationship between these factors and occupational stress, it is suggested the workplace base periodically to be changed to modify and control stress and to be paid special attention to the personnel of bases with more workload. However, the study by Seyed Javadi et al. showed no relationship between stress level and type of base [20]. Leszczynski et al. stated that EMS employees experience varying degrees of stress in terms of work place. And in fact, there was a significant difference in the occupational stress of technicians working in emergency medical services and other services (earthy emergency medical services, emergency medical departments, etc.) and they had clearly experienced less stress [23]. Similar results were obtained in other medical groups, and Yuwanich et al. showed that nurses in the emergency medical department were more exposed to occupational stress compared to nurses in other sections due to their higher workload [15]. One general conclusion is that personnel experience different level of stress in different locations and departments.
by more investigation, it was specified that stress in employees of urban bases was more in the three dimensions of demand (P=0.018), control (P=0.000) and changes (P=0.038). Therefore, it can be concluded that the main cause of more occupational stress is stress and workload (demand dimension), lack of control of person over the work doing (control dimension) and lack of adaptation to changes within the organization (change dimension) in urban bases. In this regard, Shareynia et al.
showed that there was a significant difference between the nurses in emergency and non-emergency medical department in terms of sub-scale of workload (due to high number of referrals) which increased their occupational stress [29]. Sharifi et al. stated that the dimensions of change, role, peer support, and responsible support had a significant relationship with the type of base of work [18].
The results showed that although the mean total score of occupational stress in people with experience less than 5 years and 21-30 years (both sides of the spectrum) was more than others, there was no significant relationship between work experience and occupational stress. Mati et al.
reached quite similar results and stated that there was no relationship between work experience and occupational stress among emergency medical technicians, but in work experience of more than 20 years, the sum of scores of stressors was higher [14]. Yuwanich et al. [15] stated that low experience and work experience are related to occupational stress of nurses in emergency medical services and Bardhan et al. similarly indicated that work experience less than 10 years is a strong risk factor of higher occupational stress in nurses, which is somewhat consistent with the present study [27]. On the other hand, d'Ettorre et al. considered work experience related to occupational stress in burses of emergency medical services [8]. Another study also showed that by increasing work experience of personnel employed in 115, occupational stress also increased. The researchers described the finding that by increasing work experience, the overall duration of employees' presence at work placed increased and encountered stressors more [10]. Generally, it can be stated that occupational stress is present throughout the service of individuals, but it increases in those with less experience and in the late stages of service.
Although it was expected occupational security to decrease the experience of stress but employees with more permanent employment (formal and contractual) had experienced high occupational stress, however, in the present study, a significant relationship was not observed between type of employment and the occupational stress. In this regard, some studies have shown that there is a significant relationship between employment status and occupational stress among technicians employed in 115 and nurses of emergency medical department [10,28,29].
There was a significant relationship between working hours of personnel and their occupational stress, and unexpectedly, the results showed that people with the lowest working hours (less than 150 hours per month) experienced more occupational stress compared to others. This finding may be justified by the fact that being away from the workplace will increase the stress at the time of presence. However, the results of Shareinia et al. showed that there is a mild positive relationship between overtime and occupational stress; i.e the more overtime, the stress is increased in emergency medical nurses [4]. Another study showed that working hours per week was not related to occupational stress of employees employed in 115 [20].

Conclusion
Emergency medical personnel are at risk of high occupational stress due to the nature of their job.
Reducing the stress experienced by them in the workplace is critical and improves the quality of service provided to patients. Since manpower is the most important resource of any organization, senior managers should pay special attention to this issue and use the results of similar studies to develop strategies to reduce stress of employees.