Systematic Review of the Personality Profile of Paramedics: Bringing Evidence into Emergency Medical Personnel Recruitment Policy: [1]

Abstract

Aim : Because emergency medicine is extremely demanding and challenging for emergency medical personnel (EMP), it is important that the personality traits of EMP be understood. Few studies have addressed the personality traits that EMP should possess. The aim of this study was to systematically review the personality traits of EMP to establish a profile that can help identify individuals whose personalities are suited to prehospital emergency occupations.

Materials and Methods : Electronic databases, including MEDLINE, SCOPUS, CINAHL, and PsychINFO, with information accumulated from their conception to March 2015, were searched using the terms "personality," "trait," "rescue," "emergency," "medical," "services," "personnel," "paramedic," and "technician." The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was followed in this review. Data extraction was performed by two authors who independently reviewed each article.

Results : Of 398 articles found, 27 were eligible for review. A total of 9,721 paramedics had participated in the selected studies. Nearly half of the studies were performed in the USA and Australia. The paramedics scored high in conscientiousness, sensation seeking, resiliency, and empathy but low in extroversion, neuroticism, and agreeableness.

Conclusion : While high conscientiousness and low neuroticism could be assumed to be protective factors against post-traumatic stress disorder among EMP, certain personality traits, such as conscientiousness, put them at risk of burnout. The personality traits of paramedics need to be further investigated in terms of role model traits and performance indicators related to personality traits.

144

Systematic Review

Systematic Review of the Personality Prole of Paramedics: Bringing Evidence into Emergency Medical Personnel Recruitment Policy

Amir Mirhaghi1, Maryam Mirhaghi2, Atsushi Oshio3, Saeid Sarabian4

1Department of Medical-Surgical Nursing, Mashhad University of Medical Sciences, Mashhad, Iran

2Department of Clinical Psychology, Shahrood Islamic Azad University, Shahrood, Iran

3Faculty of Letters, Arts, and Sciences, Waseda University, Tokyo, Japan

4Department of Clinical Psychology, Payame Noor University, Mashhad, Iran

Abstract

Aim: Because emergency medicine is extremely demanding and challenging for emergency medical personnel (EMP), it is important that the personality traits of EMP be understood. Few studies have addressed the personality traits that EMP should possess. The aim of this study was to systematically review the personality traits of EMP to establish a prole that can help identify individuals whose personalities are suited to prehospital emergency occupations.

Materials and Methods: Electronic databases, including MEDLINE, SCOPUS, CINAHL, and PsychINFO, with information accumulated from their conception to March 2015, were searched using the terms personality, trait, rescue, emergency, medical, services, personnel, paramedic, and technician. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was followed in this review. Data extraction was performed by two authors who independently reviewed each article.

Results: Of 398 articles found, 27 were eligible for review. A total of 9,721 paramedics had participated in the selected studies. Nearly half of the studies were performed in the USA and Australia. The paramedics scored high in conscientiousness, sensation seeking, resiliency, and empathy but low in extroversion, neuroticism, and agreeableness.

Conclusion: While high conscientiousness and low neuroticism could be assumed to be protective factors against post-traumatic stress disorder among EMP, certain personality traits, such as conscientiousness, put them at risk of burnout. The personality traits of paramedics need to be further investigated in terms of role model traits and performance indicators related to personality traits.

Keywords: Personality, emergency, medical, services, paramedics

Introduction

Emergency medical services (EMSs) provide medical care for patients in life-threatening conditions in highly demanding, challenging, and interactive environments (1). In this context, emergency medical personnel (EMP) must have the ability to cope with emotionally challenging and stressful situations. Despite the many contextual variables that exist in emergency clinical practice (2), EMP have unique roles and responsibilities in dealing with stressful situations. Therefore, the personality traits of EMP have been the focus of a number of studies (3).

It would be advantageous to recognize personality traits that are congruent with emergency working conditions. Mitchell and Bray (4) indicated that a rescue person may score low in neuroticism and

openness to experience but high in extraversion, low openness to experience, high conscientiousness, high agreeableness, and sensation seeking. Although a typical rescue personality has been reported in several studies (3), few studies have concentrated on the personality traits of EMP (5, 6). These traits are associated with job performance criteria, particularly conscientiousness (7). Individuals with high conscientiousness may show higher competency or more extrovert ones may have higher social interaction than others, but both traits are necessary for EMSs. On the contrary, neuroticism would play an un-constructive role in chaotic emergency circumstances. In addition, a debate has arisen from studies addressing the issue of whether personality traits are homogenous among EMP (8). Wagner et al. (3) concluded that there is little evidence for a distinct personality type that is reective of emergency service workers as a whole. Therefore,

Correspondence to: Amir Mirhaghi e-mail: [email protected]

Received: 01.07.2016 Accepted: 18.07.2016

Copyright 2016 by Emergency Physicians Association of Turkey - Available online at www.eajem.com DOI: 10.5152/eajem.2016.80299

Eurasian J Emerg Med 2016; 15: 144-9

Mirhaghi et al.

Personality Prole of Paramedics 145

this disparity must be addressed so that the personality traits of EMP can be fully identied.

Emer gency medical personnel are typically involved in disasters and traumatic events that could contribute to the development of post-traumatic stress disorder (PTSD) (9). As PTSD and burnout are recognized as serious issues among EMP (10, 11), it is vital to identify the personality traits of EMP that would help them cope eectively with stress so that psychological health could be maintained. To this end, Chng and Eaddy (11) investigated the relationship between sensation seeking and burnout, while Sheikhbardsiri (10) evaluated the relationship between personality traits and PTSD among EMP. Thus, there is a strong rationale for obtaining comprehensive insight into personality traits that cause an individual to be susceptible to psychological disorders, particularly PTSD.

To summarize, the signicant role of EMP in EMSs, their multidimensional role in a decidedly interactive context, and the considerable occurrence of psychological disorders among EMP make it necessary to systematically review the personality traits of this group of workers to identify a personality prole that makes an individual suitable for prehospital emergency practice.

Materials and Methods

A literature review was performed to identify the personality traits of EMP. A search retrieved potentially relevant articles in electronic databases, such as MEDLINE, SCOPUS, CINAHL, and PsychINFO. The databases were searched from their conception to March 1, 2015, without any additional lters. The search terms used were personality, trait, rescue, emergency, medical, services, personnel, paramedic, and technician. The procedures used in this review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (12). Articles about the personality traits of EMP were included if they evaluated the personality of paramedics or emergency medical technicians or if they identied a rescue personality. Studies that represented gray literature, congress abstracts, reviews, case studies, and duplicate publications were excluded. Two researchers independently reviewed the titles and abstracts of all papers identied in the primary search results. Disagreements were discussed by the researchers to reach a consensus. Relevant articles found in the reference lists of the retrieved papers were also searched for (Figure 1). If necessary, the authors of the research articles were contacted to retrieve supplementary information. The nal articles were reviewed by the authors. Data extraction involved the two authors independent reviews of each article and was based on country, instrument type, participants, sample size, and the results. The methodological rigor of the studies was also assessed. The authors reviewed the extracted data together and agreed on the results of the extraction of data and quality of each article (Table 1).

Results

Of 398 articles that were found, 27 were included in the nal sample; a total of 9,721 paramedics had participated in the selected studies. Seven studies had been conducted in the US, six in Australia, two in Germany, two in Slovakia, and one each in South Africa, Austria, Canada, Sweden, Hungary, Iran, Norway, Romania, China, and England. Nine studies used researcher-constructed questionnaires, and the remaining studies used standardized instruments (Table 1).

Big ve personality and associated traits

Neuroticism: Traits related with neuroticism are being anxious, angry, emotional, worried, and insecure (7). EMP scored lower on neuroticism than the norm sample (5). Paramedics also scored signicantly lower for neuroticism than other healthcare professionals (8). Among EMP, dispatchers had signicantly higher scores than other groups for neuroticism, while ambulance drivers scored the lowest in this category (13). Furthermore, neuroticism was strongly related to the severity of stressors and to organizational conditions (14).

Extraversion: Traits related with extraversion are sociable, assertive, talkative, and active (7). EMP showed no dierences in extraversion scores compared to the norm sample (5). Paramedics also scored signicantly lower for extroversion than other healthcare professionals (8). Among paramedics, males were signicantly less introverted than females (8), and it was possible to predict decision-making based on extraversion among male paramedics (6). The choice to join EMS was solely related to extraversion in comparison with reghter jobs (15). Paramedic students scored lower for extraversion than other students in the university (16); high levels of anxiety and extraversion were negatively related to academic performance (17). Extraversion was also signicantly related to the perceptions of post-traumatic growth (PTG) (18).

The sensation-seeking trait may also be associated with extra-version. EMP scored higher on risk and competition seeking than the norm sample (5, 12). Paramedics scored insignicantly lower on risk taking than other healthcare professionals (8). Paramedics who scored high on burnout also scored high on sensation seeking (19).

Search term: "personality" or "emergency" or "paramedics" or "medical" or "services"

398 potentially relevant papers identified and screened for retrieval

357 papers excluded because clearly not relevant

41 papers retrieved for more detailed evaluation

14 papers excluded clearly not eligible

27

Figure 1. Results of the literature search and selection process

146

Mirhaghi et al.

Personality Prole of Paramedics

Eurasian J Emerg Med 2016; 15: 144-9

Table 1. Summary of findings extracted from the review literature on the personality profiles of paramedics

Study

Participants

Instrument

Results

Backus et al. (32)

125

Questionnaire about their beliefs

EMP are interested to talk about their spiritual lives. and behaviors regarding their

Those EMTs with more active spiritual lives perceive

spirituality

themselves as happier.

Grevin (26)

225

MMPI-2 PK Scale

Both paramedics and paramedic students had significantly low scores on empathy.

Palmer and Spaid (19)

91

Standardized instruments

Burnout did not correlate with the overall sensation- seeking scale.

Chng and Eaddy (11)

425

Arnett's Inventory of Sensation

EMP had significantly higher sensation-seeking scores than

Seeking and Revicki's Work-Related

the general public, but this dimension alone does not

Strain Inventory

protect them from the effects of burnout.

Adjective checklist and 23-item

EMT now/real me was significantly correlated with activity. social identities questionnaire

EMT future/real me and EMT future/ought me were both significantly correlated with commitment.

Reich (38)

31

Brown et al. (39)

361

46-item core survey and a 16-item

Being able to help others was the most important and

survey

satisfying aspect of work life of EMP.

The Bell Object Relations and Reality

EMP with personality patterns characterized by

Testing Inventory (BORRTI)

suspiciousness, hostility, and isolation and who had a tendency toward demanding, controlling, and manipulative behavior in relationships were more likely to have taken a mental health stress leave.

Regehr et al. (34)

86

Fannin & Dabbs (2003) (15)

195

Questionnaires

EMS performance was predicted by extraversion. EMS performance was related to an interaction of testosterone with conscientiousness.

Jonsson and Segesten (23)

362

Professional Self-Description Form

Stress tolerance, consideration, and flexibility had the

(PSDF)

highest rank among the 21 self-description items named by ambulance personnel.

Kilner (31)

34

Questionnaire

Honesty, patient-centered approach and having caring, empathic and values life from technicians viewpoint.

Louria (17)

53

16 Personality Factor Questionnaire

Five factors were found to be significant in relation to

academic achievement on this course. These included abstract, verbal reasoning, levels of anxiety, levels of extraversion, work methods, and year level of study.

(the 16 PF)

Shakespeare-Finch et al. (18)

526

Questionnaire

Correlations revealed that extraversion, openness, agreeableness, conscientiousness, and coping levels significantly relate to perceptions of PTG.

Meta-emotion scale, Mindful

Meta-emotions would allow for a meaningful attention and awareness scale,

differentiation of processes in emotion regulation. positive affectivity and negative

Experiential avoidance is consistently negatively correlated

Mitmansgruber et al. (20)

239

affectivity scale

with well-being.

Sterud et al. (14)

1180

Basic Character Inventory

Neuroticism was related to higher severity scores in all stressor dimensions except for time pressure. Neuroticism was related to both severity and frequency of lack of sup port from co-workers and leaders.

Pajonk et al. (8)

245

Hamburg Personality Inventory

Results revealed differences for nervousness, extraversion,

(HPA)

control, and altruism but not for openness and risk taking.

Pilarik and Sarmany-Schuller

92

The Iowa Gambling Task,

In men, it was possible to predict appropriate decision-

(6)

EQTM map, Stroop test,

making based on emotional stability, extraversion, and

Rational-Experiential Inventory,

quick reactions. Appropriate decision-making of female

paramedics could be predicted based on two zones of emotional intelligence (low emotional awareness and positive current conditions) and on quick reactions in the Stroop test.

NEO-FFI questionnaire

Abedi et al. (16)

492

The NEOFive-Factor Inventory

Paramedical students were more introverted than others.

(NEO-FFI)

Eurasian J Emerg Med 2016; 15: 144-9

Mirhaghi et al.

Personality Prole of Paramedics 147

Table 1. Summary of findings extracted from the review literature on the personality profiles of paramedics (continued)

Gayton and Lovell (24)

219

The 10-item ConnorDavidson

These results showed that higher resiliency was significantly

Resilience Scale

associated with better general health and well-being.

Williams et al. (27)

783

Medical Condition Regard Scale

Females had higher mean scores than males on each

medical condition, supporting the multitude of empathy studies in healthcare students, where females were identified as being more empathetic than their male

(MCRS)

counterparts.

Williams et al. (28)

783

Jefferson Scale of Physician

Females had greater mean empathy scores than males:

EmpathyHealth Profession Students

108.69 vs 103.58 (p=0.042).

Juriov and Sarmny-

134

Melbourne Decision-Making

Significant relationships between components and factors

Schuller (22)

Questionnaire, MDMQ,

of mental integration (emotional and regulatory

invariability, lower mental arousal) were found. Their integration forms a calm, mentally stable and resilient personality type.

Questionnaire SPARO

Critical Incident Stress Debriefing,

EMS personnel scored lower on neuroticism and openness

Hamburg Personality Inventory

but higher on conscientiousness and risk and competition seeking than a norm sample. EMS personnel showed lower scores for agreeableness and no differences for extraversion. EMS volunteers did not differ from EMS professionals regarding personality, except for the degree of extraversion.

Klee and Renner (5)

173

The Big Fiveplus Personality

The results revealed a series of significant personality

Inventory, Sensation Seeking Scale

differences among professional groups of ambulance workers. The high-level performance dispatchers group showed significant differences from the low-level performance group of the same category regarding their scores to the following personality scales and subscales: conscientiousness, self-efficacy, and achievement striving.

Niculita (13)

458

Fjeldheim et al. (25)

131

ConnorDavidson Resilience Scale

Participants meeting PTSD criteria also had significantly

lower levels of resiliency and social support. Participants meeting criteria for PTSD had significantly higher rates of depression, perceived stress, and physical health symptoms and significantly lower rates of resiliency and social support.

(CD-RISC)

Sheikhbardsiri (10)

180

The NEO Five-Factor Inventory and

PTSD of EMP was significantly correlated with personality the Mississippi combat-related PTSD

traits of conscientiousness and neuroticism.

scale

Jefferson Scale of Physician

Empathy did not decline during course progression with

Empathy Health Profession

third-year students recording the highest mean empathy

Students version (JSPE-HPS)

score across all 3 years.

Williams et al. (29)

1719

Jefferson Scale of Physician

Overall, self-reported empathetic regard for each medical

Empathy Health Profession

condition included intellectual disability, substance abuse,

Students version (JSPE-HPS)

attempted suicide, and acute mental illness. For students as a whole, mean scores generally improved over their course as they progressed through their degree. This study found that compared to males, females generally have a higher regard for patients presenting with intellectual disability, substance abuse, and attempted suicide.

Williams et al. (30)

554

Among reghters, the preference for reghting over EMS work was predicted by the characteristic of fearlessness (15).

Openness to experience: Traits related with openness to experience are being imaginative, cultured, curious, broad-minded, and artistically sensitive (7). EMP scored lower on openness than the norm sample (5). The review also indicated that there was no dierence between paramedics and other healthcare professionals in terms of openness to experience (8). Ambulance worker professional groups scored lower on openness to experience than doctors (13). Among reghters,

individuals who preferred reghting over EMS work were predicted by low scores for openness to experience (15). Perceptions of PTG were signicantly related to openness to experience (18). Experiential avoidance related to lower scores for openness to experience was consistently negatively correlated with well-being among EMP (20).

Conscientiousness: Traits related with conscientiousness are being careful, thorough, responsible, and organized (7). EMP scored higher on conscientiousness than the norm sample (5, 21). Conscientiousness was signicantly related to perceptions of PTG (18). Resilien-

148

Mirhaghi et al.

Personality Prole of Paramedics

Eurasian J Emerg Med 2016; 15: 144-9

cy related positively to conscientiousness and negatively to neuroticism. Consequently, 5070% of EMP could be characterized as resilient (8). Conscientiousness was due to the integration of emotional and regulatory invariability and lower mental arousal (22). Stress tolerance ranked highest among the 21 items in ambulance personnels self-description measuring ambulance attendants perceptions of personality (23). Higher resiliency scores were signicantly associated with better general health and well-being (24). Participants meeting PTSD criteria also had signicantly lower scores for resiliency (25).

Agreeableness: Traits related with agreeableness are being exible, trusting, cooperative, forgiving, and tolerant (7). EMP had lower scores for agreeableness than the norm sample (5). Among reghters, the preference for reghting over EMS work was predicted by a low score for the characteristic of agreeableness (15). Agreeableness signicantly related to perceptions of PTG (18). Altruism scores were also high among paramedics, the dierence being signicant only in comparison with doctors (8). Both paramedics and paramedic students had signicantly low scores for empathy (26). However, female paramedic students were identied as being more empathetic than their male counterparts (27-29). In general, empathy levels either declined (27) or improved (28, 29, 30) as students progressed through their coursework programs. Paramedic students (in response to empathy for medical conditions) scored the lowest for substance abuse and the highest for intellectual disability (27). Honesty is one of the dimensions of the HEXACO (honesty-humility, emotionality, extraversion, agreeableness, conscientiousness, and openness to experience) personality model, and some of the characteristics categorized under honesty-humility are incorporated into the big ves agreeableness factor. Honesty was the most important characteristic reported by EMP (31). EMP are spiritual but not more so than the average civilian, and EMP with more active spiritual lives perceive themselves as happier (32). Although help is not a personality trait, helping behavior or prosocial behavior is also related to the big ve traits, particularly to agreeableness. EMP reported that being able to help others was the most important and satisfying aspect of their work.

Discussion

Paramedics have been shown to score high for conscientiousness (5, 22). This means that they make every eort to be extremely thorough when administering EMSs (4). Life-threatening conditions require the attention of organized and responsible personnel, indicating that conscientiousness is a vital trait for paramedics. In addition, there is a signicant dierence in the key trait of conscientiousness between high- and low-level performance groups of dispatchers (13). Therefore, conscientiousness is recognized as an essential trait for EMP. However, the trait of conscientiousness may occasionally put paramedics at a disadvantage. Penterman et al. concluded that workers who score high on conscientiousness are sometimes inexible in their responses during patient interactions, so the patient might quickly become irritated (21). It has also been reported that PTSD is signicantly correlated with the personality trait of conscientiousness; however, this result requires further investigation (11).

It has also been shown that paramedics score high on sensation seeking (5, 12, 19). Due to the varied, new, complex, and intense situations that exist in the clinical practices of EMP, it would appear that the trait of sensation seeking is tting in individuals who assume paramedic roles. Sensation seeking has been recognized as a common trait in rescue workers (4). Chng and Eaddy (11) showed a weak correlation between sensation seeking and burnout; however,

Palmer and Spaid showed that, overall, burnout is not correlated with sensation seeking (19).

Paramedics had low scores for neuroticism (5, 8). As Mitchell and Bray (4) indicated, people involved in rescue work may benet from a calm and measured attitude (low neuroticism). Emotional stability is vital for paramedics who are involved in life-threatening medical situations in daily clinical practice (5), where they are required to remain controlled in many emergency situations and feel secure. Low neuroticism may indicate that paramedics are using eective coping mechanisms in response to stressful situations (19). In addition, neuroticism is signicantly correlated with PTSD in EMP (11). It should be noted that these traits are not homogenous for all EMP. In contrast, dispatchers scored higher in neuroticism. Niculita mentioned that this might be related to their inability to stabilize a callers situation or to provide the necessary assistance (13). Therefore, it is vital to implement eective interventions to lessen the eects of PTSD, particularly among dispatchers (33). As PTSD is signicantly associated with lower levels of resiliency (34) and as resiliency relates positively to conscientiousness and negatively to neuroticism (8), resiliency should be considered as a protective trait for EMP.

Paramedics scored lower in extraversion (8). Although being introverted may seem to prevent the engagement of paramedics in intense personal interactions, being sociable, talkative, and active have been reported as appropriate traits for paramedics and for all individuals involved in rescue operations and engaged in daily interaction and communication with people (4). Several studies have conrmed that extraversion is one of the personality traits negatively associated with burnout (35). In addition, a tendency to be more optimistic may result in extroverted paramedics experiencing more feelings of satisfaction with their work (36).

Paramedics have also shown lower scores in openness to experience and agreeableness (5, 8). Mitchell and Bray (4) indicated that high agreeableness and low openness are optimal personality traits for rescue workers. Empathetic, highly dedicated, and a strong need to rescue others are key traits of the role models of paramedics (8, 36). Klee and Renner (5) discussed the discrepancy between low agreeableness and empathetic attitude, which may be related to the construct validity of the personality scales. Paramedics did not show imaginative and independent personalities (5, 8). This trait may be instrumental in their ability to precisely follow routines and procedures. Thus, it may be assumed that paramedics are resistant to new experiences.

Personality traits are related to burnout (37). Chng and Eaddy (11) reported that there may be no relationship between sensation seeking and burnout among EMP in spite of the weak positive correlation, so sensation-seeking or extroversion traits may not protect EMP from burnout. However, Sheikhbardsiri (10) showed that conscientiousness and neuroticism were signicantly correlated with the Mississippi combat-related PTSD scores, suggesting that these personality traits accelerate burnout. These ndings have been conrmed by Alarcon et al. (37), who meta-analytically indicated that neuroticism, extraversion, and conscientiousness are related to burnout.

Emer gency medical personnel personality traits are congruent with professional practice in accordance with contemporary factor models for personality. The personality traits of EMP suer from limited evidence and require further investigation, particularly to elucidate the association of the identied traits with certain critical disorders, such as PTSD and burnout (38, 39). Our review is limited due to the absence of randomized clinical trials in the eld of personality traits of EMP and their association with work performance and professional prociency, so a more rigorous design method is recommended.

Eurasian J Emerg Med 2016; 15: 144-9

Mirhaghi et al.

Personality Prole of Paramedics 149

Conclusion

Paramedics score high in conscientiousness, sensation seeking, resiliency, and empathy, but low in extroversion, neuroticism, and agreeableness. While high conscientiousness and low neuroticism could be assumed to be protective traits against PTSD in EMP, certain personality traits, such as conscientiousness, that help paramedics provide patients with secure medical service, also put them at risk of burnout. Further investigations into the personality traits of para-medics role models and performance indicators related to personality traits is required.

Peer-review: Externally peer-reviewed.

Conict of Interest: No conict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no nancial support.

References

1. Malekzadeh J, Shafaee H, Behnam-Vashani H, Mirhaghi A. The effect of cincinnati prehospital stroke scale on telephone triage of stroke patients: evidence-base practice in emergency medical center. Int J Evid

Based Healthc 2015; 13: 87-92. http://dx.doi.org/10.1097/XEB.0000000000000046

Web End =[CrossRef] 2. Mirhaghi A. Triage system should be compatible with culture of care in emergency department. Med Klin Intensivmed Notfmed 2016; 111: 138-9.

http://dx.doi.org/10.1007/s00063-015-0133-9

Web End =[CrossRef]

3. Wagner S, Martin C, McFee J. Investigating the "Rescue Personality". Traumatology 2009; 15: 5-12. http://dx.doi.org/10.1177/1534765609338499

Web End =[CrossRef]

4. Mitchell J, Bray G. Emergency services stress: Guidelines for preserving the health and careers of emergency services personnel. Englewood Cliffs, NJ: Prentice-Hall; 1990.

5. Klee S, Renner K. In search of the "Rescue Personality". A questionnaire study with emergency medical services personnel. Personality and Individual Differences 2013l ;54: 669-72.

6. Pilarik L, Sarmany-Schuller I. Personality predictors of decision-making of medical rescuers. Studia Psychologica 2011; 53: 175-84.

7. Barrick MR, Mount MK. The big five personality dimensions and job performance: a metaanalysis. Personnel Psychology 1991; 44: 1-26. http://dx.doi.org/10.1111/j.1744-6570.1991.tb00688.x

Web End =[CrossRef]

8. Pajonk F, Andresen B, Schneider-Axmann T, Teichmann A, Grtner U, Lubda J, et al. Personality traits of emergency physicians and paramedics.

Emerg Med J 2011; 28: 141-6. http://dx.doi.org/10.1136/emj.2009.083311

Web End =[CrossRef] 9. Barrett T, Norton V, Busam M, Boyd J, Maron D, Slovis C. Self-reported cardiac risk factors in emergency department nurses and paramedics.

Prehosp Disaster Med 2000; 15: 14-7. http://dx.doi.org/10.1017/S1049023X00025036

Web End =[CrossRef] 10. Sheikhbardsiri H. The relationship between personality traits and post-traumatic stress disorder among EMS personnel and hospital emergency staffs. Iranian Journal of Critical Care Nursing 2015; 8: 41-8.

11. Chng C, Eaddy S. Sensation seeking as it relates to burnout among emergency medical personnel: a Texas study. Prehosp Disaster Med 1999; 14: 240-4. http://dx.doi.org/10.1017/S1049023X00027709

Web End =[CrossRef]

12. Moher D, Liberati A, Tetzlaff J, Altman D, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339: b2535.

13. Niculita Z. Personality traits that foster ambulance workers' professional performance. Procedia Soc Behav Sci 2013; 78: 385-9. http://dx.doi.org/10.1016/j.sbspro.2013.04.316

Web End =[CrossRef]

14. Sterud T, Hem E, Ekeberg O, Lau B. Occupational stressors and its organizational and individual correlates: a nationwide study of Norwegian ambulance personnel. BMC Emerg Med 2008; 8: 16. http://dx.doi.org/10.1186/1471-227X-8-16

Web End =[CrossRef]

15. Fannin N, Dabbs JM. Testosterone and the work of firefighters: Fighting fires and delivering medical care. Journal of Research in Personality 2003; 37: 107-15. http://dx.doi.org/10.1016/S0092-6566(02)00533-0

Web End =[CrossRef]

16. Abedi G, Mohammadi A, Mohammadi F, Alizadeh A, Hosseini H, Rostami

F. University students' personality profile based on Casta & MaCrea Five factor theory. IJCRIMPH 2012; 4: 1330-6.17. Louria S. Academic achievement on the National Higher Diploma in Emergency Medical Care: the role of personality and study attitudes. Pretoria, South Africa: University of Pretoria; March 2007.

18. Shakespeare-Finch J, Gow K, Smith S. Personality, coping and posttraumatic growth in emergency ambulance personnel. Traumatology 2005;

11: 325-34. http://dx.doi.org/10.1177/153476560501100410

Web End =[CrossRef] 19. Palmer R, Spaid W. Authoritarianism, inner/other directedness, and sensation seeking in firefighter/paramedics: their relationship with burnout.

Prehosp Disaster Med 1996; 11: 11-5. http://dx.doi.org/10.1017/S1049023X0004228X

Web End =[CrossRef] 20. Mitmansgruber H, Beck T, Schssler G. ''Mindful helpers": Experiential avoidance, meta-emotions, and emotion regulation in paramedics. J Res

Pers 2008; 42: 1358-63. http://dx.doi.org/10.1016/j.jrp.2008.03.012

Web End =[CrossRef] 21. Penterman E, van der Staak C, Nijman H. Estimating and reporting aggression in relation to personal characteristics of emergency service workers. Tijdschr Psychiatr 2014; 56: 448-54.

22. Juriov E, Sarmny-Schuller I. Structure of basal psychical self-regulation and personality integration in relation to coping strategies in decision-making in paramedics. Studia Psychologica 2013; 55: 3-17.

23. Jonsson A, Segesten K. Daily stress and concept of self in Swedish ambulance personnel. Prehosp Disaster Med 2004; 19: 226-34. http://dx.doi.org/10.1017/S1049023X00001825

Web End =[CrossRef]

24. Gayton SD, Lovell GP. Resilience in ambulance service paramedics and its relationships with well-being and general health. Traumatology 2012;

18: 58-64. http://dx.doi.org/10.1177/1534765610396727

Web End =[CrossRef] 25. Fjeldheim C, Nthling J, Pretorius K, Basson M, Ganasen K, Heneke R, et al. Trauma exposure, posttraumatic stress disorder and the effect of explanatory variables in paramedic trainees. BMC Emerg Med 2014; 14: 11. http://dx.doi.org/10.1186/1471-227X-14-11

Web End =[CrossRef]

26. Grevin F. Posttraumatic stress disorder, ego defense mechanisms, and empathy among urban paramedics. Psychol Rep 1996; 79: 483-95. http://dx.doi.org/10.2466/pr0.1996.79.2.483

Web End =[CrossRef]

27. Williams B, Boyle M, Brightwell R, Devenish S, Hartley P, McCall M, et al. An assessment of undergraduate paramedic students' empathy levels.

Int J Med Educ 2012; 3: 98-102. http://dx.doi.org/10.5116/ijme.4fba.9190

Web End =[CrossRef] 28. Williams B, Boyle M, Brightwell R, Devenish S, Hartley P, McCall M, et al. Paramedic empathy levels: results from seven Australian universities. International Journal of Emergency Services 2012; 1: 111-21. http://dx.doi.org/10.1108/20470891211275902

Web End =[CrossRef]

29. Williams B, Boyle M, Fielder C. Empathetic attitudes of undergraduate paramedic and nursing students towards four medical conditions: a three-year longitudinal study. Nurse Educ Today 2015; 35: e14-8.

30. Williams B, Boyle M, Tozer-Jones J, Devenish S, Hartley P, McCall M, et al. Undergraduate paramedic students' empathy levels: A two-year longitudinal study. J Nurs Educ Pract 2015; 5: 58-64.

31. Kilner T. Desirable attributes of the ambulance technician, paramedic, and clinical supervisor: findings from a Delphi study. Emerg Med J 2004;

21: 374-8. http://dx.doi.org/10.1136/emj.2003.008243

Web End =[CrossRef] 32. Backus CJ, Backus W, Page DI. Spirituality of EMTs: a study of the spiritual nature of EMS workers and its effects on perceived happiness and prayers for patients. Prehosp Disaster Med 1995; 10: 168-73. http://dx.doi.org/10.1017/S1049023X00041959

Web End =[CrossRef]

33. Freedman SA, Dayan E, Kimelman YB, Weissman H, Eitan R. Early intervention for preventing posttraumatic stress disorder: an Internet-based virtual reality treatment. Eur J Psychotraumatol 2015; 6: 25608. http://dx.doi.org/10.3402/ejpt.v6.25608

Web End =[CrossRef]

34. Regehr C, Goldberg G, Glancy G, Knott T. Posttraumatic symptoms and disability in paramedics. Can J Psychiatry 2002; 47: 953-8.

35. Handelsman JB. The Relationships Between Individual Characteristics, Work Factors, and Emotional Labor Strategies in the Prediction of Burnout among Mental Health Service Providers: University of South Florida; 2012.

36. Costa P, McCrae R. The five-factor model of personality and its relevance to personality disorders. Journal of Personality Disorders 1992; 6: 343-59. http://dx.doi.org/10.1521/pedi.1992.6.4.343

Web End =[CrossRef]

37. Alarcon G, Eschleman KJ, Bowling NA. Relationships between personality variables and burnout: A meta-analysis. Work Stress 2009; 23: 244-63. http://dx.doi.org/10.1080/02678370903282600

Web End =[CrossRef]

38. Reich W. Identity structure, narrative accounts, and commitment to a volunteer role. J Psychol 2000; 134: 422-34. http://dx.doi.org/10.1080/00223980009598226

Web End =[CrossRef]

39. Brown WE Jr, Dickison PD, Misselbeck WJ, Levine R. Longitudinal Emergency Medical Technician Attribute and Demographic Study (LEADS): an interim report. Prehosp Emerg Care 2002; 6: 433-9.