Role of demographic variables in investigating occupational stress of disaster and emergency medical management center 115

Background: The Emergency Medical Services (EMS) Center is a community-centric that coordinates with the entire health care system. Employees are the most crucial asset of this medical center. This present study investigates the role of demographic variables associated with 115 disasters and the occupational stress of emergency medical management center personnel in 2019. Methods: This present descriptive study selected a statistical population based on 200 medical personnel associated with disaster and emergency medical management center 115 in Iran, according to inclusion chosen criteria. The review used a scale consisting of two parts, including demographic information and HSE standard questionnaire. The study selected respondents through Cochran's Sample Size Formula using strati�ed random sampling with a cross-sectional research design for data collection. The study has analyzed received data by using SPSS version 24 and performed the descriptive and inferential statistics (t-test and one-way ANOVA) at a signi�cance level p<0.05. Results: The study results showed the mean score of total occupational stress 3.41±0.26. The results showed the highest (4.34±0.35) and the lowest stress levels (2.72±0.86) related to role dimensions. The study �ndings revealed a signi�cant relationship between stress level and participants’ age, marital status, educational level, type of base, workplace, and the number of work hours per month. There was no relationship between the type of employment and work experience with stress levels. Conclusion: Emergency medical personnel experience a high level of occupational stress. Senior managers can use similar studies to implement measures to reduce the experience of employees' stress.


Background
Stress is an inevitable and essential part of life and follows a pervasive phenomenon, and it spreads widely throughout the life of employees.Occupational stress determines the condition of psychological stress associated with employees' work.It usually originates from pressures, which do not align with employees' skills, knowledge, or expectations.Job stress might increase when workloads are often excessive or too low.Workers often experience stress at the workplace, which keeps them motivated for their survival and growth.It affects employees regardless of their age, gender, race, economic status, or education level.Although it is a natural and necessary aspect of life, if the stress is severe, persistent, or repetitive, the individual maybe is unable to cope with it effectively.In the event where support resources are scarce, and casualties are increasingly more, stress refers to a negative phenomenon or catastrophe, which may cause physical and mental disorders [1].Occupational stress has become a common and neglected issue in the workplace, creating negative consequences, and an overall high cost for organizations.As a result, the United Nations has called it a twentieth-century disease.In recent years, the World Health Organization (WHO) has declared it a widespread problem worldwide [2].Numerous studies have shown the role of occupational stress in connection with disease symptoms, high labor displacement, and individuals' early retirement [3,4].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 [5,6].
In this regard, several organizations have implemented measures to protect the health and well-being of their employees.One of these organizations is the Disaster and Emergency Medical Management Center, which is responsible for providing clinical care to patients in a pre-hospital medical emergency and transferring to medical centers if necessary [7,8].Emergency Medical Services (EMS) staff are typically the rst health professionals to participate in intensive care, providing care to injured and critically ill patients, suspended between life and death.As a result, these people often face speci c conditions in which they experience professional stress [9,10].
Health center is one of the main pillars of emergency health care units in all countries around the globe.
According to the world's modern scienti c standards, this system's most fundamental goal is to provide satisfactory services in the shortest possible time to the patients.[11].Emergency medical services units differ from the other sections through a variety of ways, such as stressful environments, high pressure, the sensitivity of seconds, extraordinary stress on timely diagnosis, expectations and intimidation of near and dear ones, and the importance of protecting patients' lives [12].Therefore, this is the highly stressed area of the medical services unit.The emergency medical services system is a part of a chain system responsible for patients' care from the severe critical time to their rehabilitation and discharge [13].The personnel employed in this section are as the rst individuals to respond to patients in emergency medical situations and the rst sight of the critical moment [14].This section provides the conditions in creating stress for the personnel employed in this sector due to time constraints in performing affairs, the critical status of the patient, expectations of companions, the openness of the environment, fear of inadequacy in rescuing a dying patient, decision-making power in urgent situations and factors related to workforce [15,16].
The prolonged exposure of emergency medical personnel to unpredictable stress settings leads to some scholars to classify them as people at high risk of exposure to PTSD [17,18].Besides, if stress is not adequately addressed and properly managed in the right way, it can lead to many physical and psychological symptoms of EMS staff [19].Some of such symptoms refer to anxiety [20,21], depression [22], , sleep disorders, fatigue and unsafe behavior [23], gastrointestinal symptoms, backache [24], diminished occupational satisfaction [25], occupational burnout[26], emotional disturbance, and depersonalization [27,28].
Increasing working hours causes an increase in con ict in occupational and family tasks, leading to occupational stress [29].The rotating nature of work shifts of emergency medical technicians gives little opportunity to adapt to sleep patterns that can disrupt mental health [30].Consequently, the effects of day and night shifts can be fatigue, sleep disorder, gastrointestinal disorders, and poor performance [31].In domestic studies, Shari et al., in their research in Kerman, concluded that about half of emergency medical personnel experienced moderate occupational stress.There was a signi cant relationship between occupational stress with educational level and employment status, while age and marital status didn't have any relationship with stress [32].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 critical factor of stress load is occupational, environmental factors, and factors related to a patient.There was also a signi cant relationship between the amount of stress load with the number of missions, educational degree, and type of base and employment status [33].Seyed Javadi et al., in a study conducted on employees in 115 provinces of Ardabil, stated a signi cant correlation between age and occupational stress.Still, there was no relationship between stress and marital status, educational level, type of workplace base, and working hours per week [34].
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 compared to the other 25 jobs [35].The results of a study conducted in Turkey demonstrated that all the stressful and unfavorable conditions in the pre-hospital emergency medical services lead to the personnel's physical and psychological fatigue and eventually lead to burnout development [36].Leszczynski et al. emphasized that physicians and nurses in the emergency medical services department suffered more burnout than emergency medical personnel did.They stated that emergency medical service personnel experienced the least amount of burnout compared to their colleagues [37].Besides, the problems discussed above, emergency medical personnel employed by the Iranian Government's health-care system are involved in addressing other challenges, such as staff shortages, inadequate equipment, inadequate training of the necessary standards, interaction with people, skills training issues, anxiety and various forms of emotional distress [9,38].Despite all the studies conducted, reviewing different backgrounds indicates that no research was conducted in Kermanshah University of Medical Sciences to assess the occupational stress of the personnel employed in 115 of the Kermanshah provinces.Thus, keeping in view the stature of job, occupational stress is prominent in emergency medical workers, which is considered a key element in health systems.It provides the optimal provision of health care and clinical services for affected at a critical moment.This study focused on investigating the personnel's occupational stress status of the disaster and emergency medical management center 115, and the role of demographic variables play in 2019.This issue enables planning and comparison with other areas of the country while identifying speci c cases supporting counseling and treatment.

Method Study design
This cross-sectional descriptive study lasted from May to September 2019.This present descriptive study selected a statistical population based on 200 medical personnel associated with disaster and emergency medical management center 115 a liated to Kermanshah University of Medical Sciences and designated sample size by using Cochran formula (95% con dence level and 5% error) in Iran, according to inclusion chosen criteria.The review used a scale consisting of two parts, including demographic information and HSE standard questionnaire.The study selected respondents through Cochran's Sample Size Formula using strati ed random sampling with a cross-sectional research design for data collection.In this study, the investigators recruited 85 urban base personnel and 115 personnel of emergency medical road bases of 115 in this statistical sample to draw the results.The study analyzed received data using SPSS version 24 and performed the descriptive and inferential statistics (t-test and one-way ANOVA) at a signi cance level p<0.05.The study criteria consisted of the personnel list, individuals, and road, which speci ed the selection criteria.
The Research Ethics Committee of Kermanshah University of Medical Sciences approved this research project, and the authors obtained the informed consent form from all the participants of the study units.The authors asked respondents to ll the questionnaire forms at home to avoid the fatigue of the sample units of this present study.The participants needed 15-20 minutes to provide their feedback on the questionnaire and the authors collected the required data sets in nine weeks.The inclusion criteria required were as follows.(1.) Be employed in the pre-hospital emergency medical ambulance, as one of the technical categories rescuer, primary, middle and senior technician, and the authors did not include technicians employed in o ce and communication center.(2.)The technician's main job 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.The exclusion criteria removed those participants who did not show a willingness to participate in the survey or provided incomplete questionnaire forms.The authors explained that taking part in this research is optional, and all the received information would be strictly con dential.The researchers' team provided the self-reported questionnaires to eight faculty members of the school of nursing, psychology, emergency medicine, and six emergency medical personnel to determine the tool's face and content validity.

Tools
This present study incorporated a self-reported instrument to collect the desire data sets.The questionnaire had two-parts to record the selected respondents' feedback by using Cochran's Sample Size Formula.This study cross-sectional research design used strati ed random sampling to collect the required data for further analysis.In the next phase, the authors analyzed data units by incorporating SPSS version-24 to perform the descriptive and inferential statistics (t-test and one-way ANOVA) at a signi cance level p<0.05.The rst part of the scale reported demographic variables, such as respondents" age, marital status, level and eld of education, work experience, employment status, the workplace (urban, road, both), and categorized by hours of work per month.The second part described the standard occupational stress questionnaire related to the British Health and Safety Executive (HSE) [35].This selfreported questionnaire contains 35-items with seven sub-scales of items.The demand covered questions related to workload, characteristics, and work environment with eight items (questions 3, 6, 9, 12, 16, 18, 20, and 22).The control speci ed to queries how it could assess that a person is on keeping a path of effectively doing his/her job with six items, including (questions 2, 10, 15, 19, 25, and 30).The support of authorities signi es the amount of support a person receives from their management and service organization categorized with ve items (questions 8, 23, 29, 33, and 35).The support of colleagues' measures the amount of support that a person receives from his/her colleagues.It was allocated with four items (questions 7, 24, 27, and 31).The relationship characterizes with an increase in practice and positive attributes to increase mass communication and reduce workplace con ict.It has a distribution of 4 items (questions 5, 14, 21, and 34), and the role attributes to the right understanding of personnel from their organization allocates ve items (Questions 1, 4, 11, 13, and 17).Changes that address how to organize and change an organization's forces measure the outcome with three items (questions 26, 28, and 32).The questions of this questionnaire include a ve-point Likert scale (never, rarely, sometimes, often, and always) that scores from 1 to 5, respectively.A high score from this questionnaire indicate less occupational stress [14].The occupational stress questionnaire (HSE) was valid and reliable in a previous study conducted by Azad Marzabadi et al.The study showed a 78% reliability level based on Cronbach's alpha coe cient [39].Its internal consistency was 89% based on Cronbach's alpha coe cient.

Data Analysis
In the next phase, this descriptive research study performed the analysis to draw the results.The study used descriptive analysis (frequency, percentage, mean and standard deviation) and inferential statistics (ANOVA and independent t-test) and SPSS statistical software version 24.0 by using a signi cance level set at p<0.05.

Ethical approval
The authors obtained ethical approval from the Ethical Review Committee of Kermanshah University of Medical Sciences (KUMS).The research team explained the study's purpose to all participants and obtained the written informed consent from all participants.The authors assured all the respondents their anonymity and con dentiality.

Results
The results showed that the mean age of the participants was 30.14, with a standard deviation of 5.96 years.The study results showed the mean score of total occupational stress 3.41±0.26.The results showed the highest (4.34±0.35)and the lowest stress levels (2.72±0.86)related to role dimensions.The study ndings revealed a signi cant relationship between stress level and participants' age, marital status, educational level, type of base, workplace, and the number of work hours per month.There was no relationship between the type of employment and work experience with stress levels.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 individuals (80%) had an emergency medical degree.Nearly half of the individuals (47.5%) had less than ve years of work experience, and 35.5% worked on the majority of the project.Concerning the type of base to the workplace, 42.5% of individuals were in the urban ground, and 57.5% in the road base.More than half of them (58%) worked between 200 and 250 hours per month (Table 1).The mean total score of occupational stress in single individuals (3.48±0.29)was higher as compared to married individuals (3.35±0.23).The independent t-test showed a signi cant 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 signi cantly higher than road base (3.34±0.26)(P=0.000)(Table 1).
The ANOVA test result showed that the total mean scores of occupational stress had decreased signi cantly with increasing age (P=0.000).ANOVA test showed a signi cant relationship between job stress with educational level and eld of education (P=0.000),individuals with master's degrees had higher occupational stress score (3.60±0.07),and individuals with an emergency medical degree had a lower score (3.37±0.26)compared to other grades and elds.On the other hand, the results of this test showed that there is a signi cant relationship between occupational stress score and working hours per month (P=0.000);therefore, 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 signi cant relationship between work experience (P=0.092) and type of employment (P=0.241) with occupational stress score (Table 1).
The mean and standard deviation of the total score of occupational stress was 3.41±0.26.The highest and the lowest level of occupational stress showed a relation to role dimensions (4.34±0.35)and changes (2.72±0.86)(Table 2).The mean score of stress in terms of demand, control, and change showed a signi cant relationship with the type of base of the workplace (P<0.05).Hence, the mean score in all these dimensions in urban bases employed was more than road bases (Table 3).

Discussion
The purpose of this study was to investigate the job stress levels of the personnel of the Accident and Emergency Management Center (Emergency Medical Services 115, EMS) and the role of demographic variables in 2019.The results showed that the highest and lowest job stress levels indicated an association with role and change dimensions, respectively.The role domain measures "people's right understanding of working in the organization."Therefore, in the present study, it seems that people had insu cient knowledge about their duties and responsibilities, goals, and views of the organization and their expectations in the workplace.On the other hand, the change domain is related to "how to organize and change the organization's forces."Therefore, in the present study, the o cials acted strongly in this regard, and there is a good relationship between them and the staff regarding Intra organizational changes.In this regard, Hosseinzadeh et al. stated that the highest and lowest job stress levels in emergency medical personnel speci ed a link to the role and demand domains [40].Shari et al. reported that the demand dimension had the highest, and the role dimension had the lowest level of job stress among emergency medical personnel [32].Mei Lu et al. showed that the subscale of problems related to time and workload based on the job stress questionnaire (which is in line with the HSE questionnaire's demand dimension) was one of the subscales with the highest score among emergency nurses [41].However, Mahdizadeh et al. concluded that the workload issues do not cause much stress to EMS personnel [9].With the past studies' evidence, ndings concluded that the most substantial and weakest job stressors are very diverse and even contradictory.The characteristics and research environment of the study in uence stressors.O cials should conduct similar fundamental studies to determine the root cause of stress and subsequently correct these factors in the workplace.
The results showed that younger people experienced more job stress.Similarly, Motie et al. reported that the stress levels decreased with technicians' age to about 40 to 45 years [15].The level of job stress is normal to decrease with age and work experience; increasing age to a particular stage can play a protective role against stressors.d'Ettorre et al. stated that respondents age had a signi cant relationship with the level of job stress in emergency nurses [42].However, Seyyed Javadi et al. achieved contradictory results, so that the job stress in EMS personnel increases with age [34] and Bardhan et al. also considered age to be strongly associated with job stress levels, stating that age over 40 years is a higher risk factor for emergency nurses' stress.[43].The researchers explained their ndings by stating that as people get older, their ability to adapt and tolerate stressful work conditions decreases.It is usual for job stress to increase.This study aimed to observe an increase in stress levels among employees with more than 50 years of age in the present survey.According to the present study, unmarried workers had more job stress than married people.Similarly, Shareinia et al. stated that the stress levels were higher among single nurses [44].
However, a previous study of Seyyed Javadi et al. showed no relationship between EMS technicians' job stress and marital status [34].Conversely, Mahboubi et al. reported that married EMS personnel had a higher level of job stress [45].Recent study results indicated that there are more expectations from single people from the family and the workplace, increasing working hours and workload and thus increasing job stress.The educational level had a signi cant relationship with the level of job stress experienced by individuals.Only 2% of the participants were postgraduate students who participated more job stress than the lower grades, consistent with a study of Namdari et al.They stated that the intention to stay also decreases with increasing educational level [11].
Although increasing the educational level increases knowledge and skills, service delivery quality is expected to improve as people's expectations grow.They are often in more challenging situations and do more work that is specialized; these can increase job stress.Motie et al. concluded that technicians with a higher educational level of bachelor's degree had experienced more job stress than other people who has academic levels, such as associate degree and high school.However, there was no signi cant relationship between educational level and stressors.Their ndings may be because people in stressful situations that require quick decision-making, regardless of their educational level, may not be able to function effectively and experience high stress [15].Job stress had a signi cant relationship with individuals' educational level because the EMS degrees workforce had less job stress than other elds of study (nursing, anesthesiology, and paramedic).Similarly, Namdari et al. described that there was a signi cant relationship between job stress and the eld of study of EMS staff [11].This study's ndings showed that workers of the EMS graduates had undergone specialized academic training to provide prehospital services.Therefore, they experience less job stress than other disciplines who had typical training for hospital conditions.the results stipulate the need to employ more relevant people in EMS centers.It seems normal to choose people with a job-related degree to reduce workplace stress.This study's ndings showed that health workers in urban centers generally encountered higher job stress than road station staff.The results are consistent with the studies of Motie et al. [15] and Namdari et al. [11].Seyyed Javadi et al. conducted a study and described no relationship between job stress level and station type [34].Leszczyński et al. reported that the EMS employees experience varying degrees of occupational stress depending on the place of work because the technicians working in air EMS services had experienced less stress than other services (ground EMS services, emergency departments, etc.) [37].Other medical groups revealed similar results.Yuwanich et al. conducted a study and described that the emergency nurses were more exposed to job stress than nurses in other departments because of the higher workload in the department [29].In conclusion, the personnel in different places and departments experience different levels of job stress.Policymakers and senior managers should consider this issue.
The investigation revealed that the level of work-related stress in the three dimensions of demand, control, and change was signi cantly higher in urban station staff.Thus, results evidenced that the leading cause of more signi cant occupational stress is workload and pressure (demand dimension), lack of selfcontrol (control dimension), and non-compliance with intra-organizational changes (change dimension) in the urban stations.As a result, o cials can manage this issue by making the necessary changes in urban stations, such as reducing working hours, increasing the workforce per shift, etc.In this regard, Shareinia et al. showed a signi cant difference in workload subscale between emergency and nonemergency nurses (due to the high number of patients referred), which increased their job stress [44].Shari et al. conducted a study and identi ed that the dimensions of change, role, peer support, and chairman support indicated a signi cant relation to the type of workplace station [32].The results showed that although the mean total score of job stress was higher in people with less than ve years of experience and 21 to 30 years of age (both sides of the spectrum).There was no signi cant relationship between work experience and job stress level.Motie et al. reached the same results.They stated that there is no relationship between work experience and job stress of EMS technicians, but the total score of stressors increases in the work experience of more than 20 years [15].Yuwanich et al. stated that low experience and work experience are associated with the job stress of emergency nurses [29] and Bardhan et al. showed that less than ten years of work experience is a decisive risk factor for higher job stress in nurses, which are somewhat consistent with the present study [43].On the other hand, d'Ettorre et al.
considered work experience to be related entirely to emergency nurses' job stress [42].
Another study showed that job stress increases with increasing work experience of EMS personnel.The researchers found that prolonging work experience increases employees' overall attendance at work, and they are more exposed to stressors [11].In general, job stress is present throughout individuals' service life, but it increases among workers with less experience and the end stages of service.Although job security leads to reduced occupational stress, employees with a more permanent employment type (permanent and contractual) still experienced high job stress.However, the present study observed a signi cant relationship between work and the level of job stress.In this regard, some studies have shown that there is a notable relationship between employment status and job stress levels of EMS technicians and emergency nurses [11,34].
The relationship between staff working hours and job stress was signi cant; unexpectedly, the results showed that people with the lowest working hours (less than 150 hours per month) experienced more job stress.Perhaps this nding can be justi ed because being away from work for a more extended time increases stress during attendance.However, there is no information about people with less working hours in this study to investigate the cause of more stress in them.Shareinia et al. showed that there is a slight positive relationship between overtime and job stress, that is, the more overtime, the more stress in emergency nurses [46].Another study reported that working hours per week were not associated with job stress in EMS staff [43].According to past studies, results evidenced that working hours are not the leading cause of job stress, and there are more factors, which are critical in this regard.

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 the highest level of stress indicated a link to the role and demand, authorities should, in many ways, understand the correct people from the organization and reduce their workload.
Based on the literature evidence on this research topic, the present study's ndings provide essential information and contribute to the scienti c literature.Senior managers need to pay special attention to this issue and use similar studies to develop strategies to reduce the stress of their employees, which would result in employees' better performance.
The study was approved by the Research Ethics Committee of Kermanshah University of Medical Sciences (Code: IR.KUMS.REC.1397.869).Written informed consent was obtained from group members.All the procedures performed in the study involving human participants were based on the ethical standards of the Institutional Research Committee and the Helsinki Declaration and its later amendments or comparable ethical standards.

Consent to publish
All participants consented verbally to publication of the interview data.