This paper was originally published in the August 2009 issue of the Emergency Number Professional Magazine. The publication is no longer in print, so we are posting this here for digital reference with the permission of NENA: The 9-1-1 Association.

Burnout: A state of emotional, mental and physical exhaustion caused by excessive and prolonged stress. It occurs when you feel overwhelmed and unable to meet constant demands. As stress continues, you begin to lose the interest or motivation that led you to take on a certain role in the first place.¹

Compassion Fatigue: A state experience by those helping people in distress; it is an extreme sate of tension and preoccupation with the suffering of those being helped to the degree that it is traumatizing for the helper.²

Critical Incident Stress: A natural reaction of a normal person to an extremely abnormal situation. It may manifest itself as physical, cognitive and emotional response that may be experience almost immediately or may be delayed by days, weeks or months.³

Post Traumatic Stress Disorder (PTSD): A debilitating condition that often follows a terrifying physical or emotional event causing the person who survived the event to have persistent, frightening thoughts and memories, or flashbacks of the ordeal. Persons with PTSD often feel chronically, emotionally numb. Once referred to as "shell shock" or "battle fatigue.⁴

Help Wanted: 9-1-1 Dispatcher. Applicants must be easily irritated by 9-1-1 callers; phone slamming and swearing an asset. Preference will be given to candidates able to complain about their workload while receiving calls. Must be able to survive on donuts for breakfast, greasy takeout food in the wee hours and gallons of coffee. Punctuality and good attendance are not required, but working overtime is essential. The successful candidate should expect to be bullied by annoying senior co-workers. Remuneration: not nearly enough to put up with all this.

No one would answer this job posting. People are attracted to 9-1-1 dispatching to help people, to be part of the exciting world of the emergency services, to make a difference. Yet, if you have ever worked in a 9-1-1 communications center, you will have witnessed some of these behaviors in other 9-1-1 dispatchers and possibly even in yourself. So what happens to change an empathetic, hardworking 9-1-1 dispatcher into the person described above? Stress!

Stress is an epidemic in our 9-1-1 centres. Not the garden-variety stress of life (though it can be tossed in for good measure), but the stress associated with listening to someone else's worst day—every day—as a routine part of the job. This is the kind of stress that builds up over time (cumulative stress), and slowly erodes our ability to feel empathy (compassion fatigue). It is the stress that drops in like a sledgehammer when you hear the voice of a frantic mother screaming into the phone that she has found her son hanging in the garage (critical incident stress).

As stress increases, the 9-1-1 dispatcher puts up barriers in an effort to protect himself from the "cost of caring."⁵ The frustrations of call taking become the caller's fault (they are "stupid," they "don't know what a real emergency is," they are "rude") or the co-worker's fault ("they don't pick up their share of the 9-1-1 lines," "the lights are too bright in the dispatch center") or the boss's fault ("what does he know about this job? He never even comes in the room!").

9-1-1 dispatchers carry a heavy load. They must be ready to answer any call, to help unappreciative callers, or callers who abuse the system. But without recognizing the symptoms of stress and focusing on self-care, a good 9-1-1 dispatcher can become frustrated, irritated and stressed-out. He no longer enjoys his job and he is not very effective as an emergency 9-1-1 dispatcher. More and more 9-1-1 tapes are being released to the media. How many of them have recently featured a rude dispatcher? How much would you like to bet that the rude dispatcher is always a stressed-out dispatcher?

How Does This Happen? What is Stress Anyway?

Stress is insidious and can sneak up on the best of us with our realizing it. Not surprisingly, there are many forms of stress; everyone is affected by it and deals with it differently. All people experience stress in one form or another. There is the stress that is a normal and healthy part of life and then there is stress that is destructive to mental and physical health. A great deal of stress reduction is being able to identify the signs and symptoms of stress in your life and to take action to reduce that stress and minimize its effect on your body.

Picture a tall water glass. Into this glass goes all of the drops of stress we encounter every day—some big drops, some little drops. On a day when we encounter normal amounts of stress, this glass never gets full, yet if we experience increased stress in our personal lives and we have a high-stress job, the glass gets fuller. If stress-inducing events are not recognized and dealt with, the glass may get so full that it overflows. Once this happens, the negative effects of stress spill out all over our lives in the form of physical and mental ailments.

General stress is the normal stress of daily life. It is a state of physical and mental arousal, a demand for action.⁶ It is a necessary part of life. We would die if we didn't have some stress in our life. Stress helps us make choices; it helps us get out and do the things we need to do; it can help us develop plans, change behaviors and begin new activities. Stress is a routine and normal part of our day. Stress is good when it is controlled. People deal with it, they learn from it, they recover from it and they may actually grow from it.

Stress Types

Compassion Stress

Those in the emergency services deal with compassion stress, which is the natural behavioral and emotional response of wanting to help people. This is why a lot of 9-1-1 dispatchers choose the jobs they do. It feels good to help people. As members of a helping profession that is faced with the suffering of others, 9-1-1 dispatchers empathize with the people they are assisting. They are subject to compassion stress, but in return, they receive compassion satisfaction from their actions. It is compassion satisfaction that keeps many 9-1-1 dispatchers in the hot seat shift after shift.

Critical Incident Stress

Believe it or not, even the effects of a Critical Incident Stress (CIS) exposure are normal. According to Jeff Mitchell, Ph.D., CIS is "any situation faced by emergency service personnel that causes them to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the scene or later." Even for emergency personnel, these events are outside regular emergency workplace experiences. CIS is a normal, but painful response of normal healthy people to an abnormal event.⁷ When properly diffused and debriefed, CIS is a temporary, albeit painful, form of normal stress. 9-1-1 dispatchers need to be reminded that their normal day at work is actually abnormal. Hearing about people's pain, suffering and fear for 12 hours is challenging and it is okay to have an emotional reaction to your work. However, it is imperative that this reaction is not ignored. This can be a challenging thing for 9-1-1 dispatchers who are used to dealing with other people's problems, not their own. 9-1-1 dispatchers can feel that they are not supposed to be affected by critical incident stress. "I wasn't even there. I just talked to the guy on the phone."

It is when stress is not acknowledged or treated that it becomes destructive. CIS exposure is a work place injury just like a back injury or needle stick. There should be no stigma or shame if a call "gets to you." Recognition of CIS and its management is part of emergency services for police officers, fire fighters, paramedics and ER staff, but the dispatch personnel are too often forgotten in diffusing and debriefing sessions. Emergency 9-1-1 dispatchers are the first tier of emergency services—the access point—and must not be forgotten.

Secondary Trauma Exposure

9-1-1 dispatchers may experience Secondary Trauma Exposure—exposure to traumatic events experienced by others as a result of your work (counselor, emergency room employee, public safety telecommunicator, etc.⁸) 9-1-1 dispatchers are removed from the events and only experience them through voice and description; yet they are often present—through the phone call—as the events are happening. She is on the line with the terrified girl as someone is breaking into her home; he is giving CPR instructions and listening as a wife pleads with her husband to wake up; she is telling the trapped people how to put towels in front of the door to keep the smoke from coming in the room as they wait to be rescued. These interactions place 9-1-1 dispatchers squarely in the middle of the crisis. Sometimes, the 9-1-1 dispatcher is the last person to talk to the caller alive. Sometimes the caller can't calm down enough to follow the 9-1-1 dispatcher's life saving instructions. Sometimes the 9-1-1 dispatcher is privileged enough to hear a baby's first cry. These are all stressful events and the 9-1-1 dispatcher needs to be allowed to process them. Just the simple act of taking a 10 minute break after an intense call to drink a glass of water and walk around the block will do a great deal to relieve workplace stress.

Cumulative Stress

Cumulative Stress has no obvious trigger and may be harder to recognize. This is the build up of stressors over time. Our minds don't compartmentalize stressors, so when the 9-1-1 dispatcher arrives to begin her shift, that tall water glass may already be half full from personal life stress. It then takes less work stress for it to start to overflow. Without taking steps to manage this build-up of stressor, the cumulative effects will start negatively affecting the 9-1-1 dispatcher.

Taking a Pro-active Approach to Your Health

Unresolved and untreated stress has a number of negative manifestations, including Compassion Fatigue, Burn Out and in its most serious form, Post Traumatic Stress Disorder. How can you tell if stress has become destructive? There are a number of red flags* that could indicate that stress is having a negative impact on your life. They can manifest in six different areas of our lives:

• Physical: Fatigue, headaches, back pain, insomnia, nausea, indigestion, cramps, fainting, constipation, diarrhoea, sweatiness, sleeping too much or too little
• Mental: Forgetfulness, poor concentration, boredom, paranoia, poor teamwork, perfectionism
• Emotional: Irritability, depression, anxiety, anger, fear, mood swings, apathy, increased sensitivity to criticism
• Relational: Loneliness, withdrawal, intolerance, relationship problems
• Behavioral: Substance abuse, eating problems, risk-taking, hyperactivity, overwork, procrastination, missed deadlines, anti-social behaviour
• Spiritual: Emptiness, loss of beliefs and sense of meaning, cynicism, compassion fatigue⁹

*for educational purposes only, they are not intended to be used as a diagnostic tool

By simply reading this list, it is easy to see how a person who is suffering from the effects of destructive stress could turn into in the perfect candidate for the "help wanted" ad at the beginning of this article. Anyone suffering from any of the above symptoms is encouraged to talk to their healthcare provider. Being pro-active about your own health—and stress is a health issue—is of the utmost importance. Many Employee Assistance Plans (EAP) have stress management resources such as counselling and educational materials available to employees. It can be hard to take the first step and ask for help, but the benefits of keeping stress in the normal and healthy range will make a profound difference in quality of life.

Self-care is an important part of stress management and should be a routine part of healthy living for every emergency 9-1-1 dispatcher. It is difficult to take care of others when suffering yourself. To avoid becoming like the description ad, keep that water glass from overfilling! Make the pneumonic S.T.R.E.S.S part of your daily life. It can help remind you of how to practice self care every day.

S.T.R.E.S.S Self Care¹⁰

Sensible Eating

Do not use alcohol or drugs to cope. Drugs, and particularly alcohol, are powerful reaction suppressers—they numb the pain BUT they don't solve the problem. Talk it out—work through the problem—don't medicate it.

Diet is an important factor in reducing the negative effects of stress. Even though you may not feel hungry, eat something and make sure it's healthy food. Refined sugars, fats and excessive salt elevate stress levels. Avoid anything with caffeine in it—caffeine is a stimulant and elevates blood pressure and heart rate and creates an increased need for oxygen, it stimulates the cardiac muscle and central nervous system. It causes nervousness, sleeplessness and irritability. Drink water! Stress dehydrates and dehydration can increase feelings of anxiety and stress.

Time to Enjoy Life

You must take care of yourself—that includes doing what you enjoy. Take time for leisure activities. Active ones are particularly helpful. If the incident happened at work, and if you are very traumatized, it may be necessary to take time off from work; working while being emotionally vulnerable puts you at risk for an acute stress reaction. On the other hand, you may be someone who finds that being back on the job is just what is required. Assess your situation carefully. If you feel ready for action, return to work. If you feel vulnerable, request time off but seek professional help.

Rest and Relaxation

If we don't sleep we can actually develop psychotic symptoms. Everything seems worse when we are not sleeping well—if your sleep is effective seek advice from your doctor and implement healthy sleeping techniques (having a dark and cool room, white noise, avoiding caffeine, not eating two hours before bedtime, keeping the bedroom for sleeping and sex, not working or watching TV). Most of us breathe from our upper chest and don't breathe deeply; deep breathing is one of the most effective relaxation techniques for emergency personnel. It can be performed anywhere anytime. Learn some relaxation techniques and visual imagery

Exercise and Education

Exercise is critical to cleansing the body of the negative consequences of stress. Get some good exercise within 24 hours of the incident. Do not stop with that. Keep up regular activity, whether it's a tennis game, a run, or a brisk walk. Expect the incident to bother you; take comfort in knowing that the incident is unlikely to bother you forever. Though you will never actually totally forget the incident, remembering it does not have to cause extreme emotional distress. Your goal should not be to totally forget the incident. Rather, it should be to heal. You know you are healed when you are able to think of or talk about the incident without profound emotion. Get a book on traumatic stress and learn about it. You need facts about what you are going through. Through reading you will feel less abnormal and learn way to assist in your recovery.

Social Support of Family, Colleagues and Friends

Many people react to psychological trauma by keeping it inside. Often the trauma may seem so great that life seems meaningless. By withdrawing, you keep yourself in the dark causing the incident to become larger than life. Though you may need some time alone, eventually get to talking.

Satisfying Expression of Self and Spirituality

Do the things that you love to do and find ways of fulfilling your feelings of self worth outside of the job. Balance home life, recreation and work. Care for yourself and your family, your spouse, your friends and yourself. Seek your spiritual center. Talk to spiritual leaders and seek guidance.

Being an emergency 9-1-1 dispatcher is more than a job, it is a calling. Those brave and empathetic enough to answer 9-1-1 calls everyday need to be thanked way more often than they are. So I say, thank you for always being there. You make a difference. Be well and stay safe.