Research
Building personal resilience in primary care paramedic students,
and subsequent skill decay
Adam D Vaughan PhD, is Assistant Professor1, Adjunct Professor2 and Research Associate3; Bryce E Stoliker PhD is a sessional
researcher3; Gregory S Anderson PhD is Dean4
Affiliations:
1
School of Criminal Justice, Texas State University, United States
2
Faculty of Health Sciences, Simon Fraser University, Canada
3
Justice Institute of British Columbia, Vancouver, Canada
4
Faculty of Science, Thomson Rivers University, British Columbia, Canada
https://doi.org/10.33151/ajp.17.803

Abstract
Introduction
Paramedics are routinely exposed to traumatic incidents that include physical injuries; these events may manifest into psychosocial
injury. Proactive and preventive measures have the potential to mitigate the negative impact of exposure to traumatic events.
Enhancing an individual’s capacity to effectively manage stressful/adverse life events through an online resilience resource (ORR)
offers a promising option for paramedics. The aim of this study is to investigate the initial impact of an ORR on resilience and to
explore the potential skill decay following this self-guided online resource among pre-employment paramedic trainees.
Methods
Through a repeated measures design, 227 primary care paramedics from British Columbia, Canada completed a baseline resilience
assessment and ORR. A subset of participants completed follow-up resilience assessments at 3 to 6 month or 9-month intervals.
Results
Between the baseline and 3-month follow-up tests, results indicate that self-report resilience scores showed a slight improvement.
However, as time increased to 6 or 9 months, a statistically significant decrease in resilience scores in comparison to the baseline
was observed.
Conclusion
This study presents evidence to suggest that an educational tool such as an online self-paced training program for building
resilience may be an effective strategy for improving short-term personal resilience among primary care paramedic students. Given
the gradual skill decay associated with an ORR, we can highlight the temporal limits of resilience training. Developing additional
resilience training programs to be delivered throughout students’ pre-employment education may help reduce skill decay.
Keywords:

resilience; web-based training; paramedic; EMS; PCP
Corresponding Author: Greg S Anderson, ganderson@tru.ca

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Introduction
Due to the nature of their work, public safety personnel (PSP)
such as police officers, firefighters, correctional workers,
emergency medical technicians (EMTs) and paramedics are
highly likely to be exposed to potentially traumatic and stressinducing events (1). As a result, they are at increased risk of
developing post-traumatic stress injuries (PTSI), which may
include mental health issues such as symptoms consistent with
anxiety, depression, as well as the adoption of maladaptive
coping styles (2-6). In general, PTSI could have deleterious
effects on PSP, potentially leading to a reduced quality in
occupational performance, increased absenteeism, attrition,
sleep difficulties, interpersonal issues, burnout, substance use,
and suicidal thoughts and behaviour (2-4,6,7).
Among EMTs/paramedics in particular, mental health issues
and suicidal thoughts and behaviour are prominent (2,5-8)
which may be – at least partially – attributable to the fact that
they are often exposed to varying forms of human suffering to
which they feel some level of responsibility (2,6,9). Carleton
and colleagues (2) reported that 49.1% of paramedics
screened positive for symptoms consistent with one or more
mental disorders, with symptoms of depression and PTSI
being the most commonly occurring mental health problems
among this group of PSP. Carleton and colleagues (7) have
also shown that paramedics reported statistically significantly
higher prevalence of past-year and lifetime suicidality
compared to other PSP. Given the nature of their work, and the
prevalence of mental health and suicide-related issues, EMTs/
paramedics would benefit from formal training that aims to build
resilience and provide the necessary tools to maintain healthy
psychological functioning.
Research has shown that resilience – an individual’s capacity
to effectively manage stressful/adverse life events (10-15) – is
associated with wellbeing and that this association may be
enhanced through appropriate interventions (16). However,
the effectiveness of preventive/proactive programs that aim to
educate EMTs/paramedics such as those that focus on building
resilience to mitigate the effects of working in potentially
traumatic and stressful environments are limited. Accordingly,
researchers at the Justice Institute of British Columbia (JIBC)
designed one of the first self-paced online resilience-building
courses in Canada (hereafter referred to as the online
resilience resource; ORR) to help PSP build resilience to
increase mental wellness and psychological readiness for
working in trauma-exposed fields (17).
The aim of this study is to investigate the initial impact of
the ORR on resilience and to explore the potential skill
decay following this self-guided online resource among preemployment paramedic trainees. Training and educational
requirements are complex policies in PSP contexts and are
often fixed to resource and staffing levels. Identifying the

point at which certain skills, such as those adopted through
resilience training, may begin to decay, provides stakeholders
with knowledge of when it may be appropriate to refresh the
skills of PSP.

Methods
Study design
Through a repeated-measures research design, this study
investigated the effectiveness of the ORR (17) as an
educational tool for building personal resilience among a
sample of paramedic students enrolled in a primary care
paramedic (PCP) program.
Setting
PCP students were recruited from JIBC, a post-secondary
institution that provides training to professionals in the justice,
public safety and social service fields. The study was based
entirely online. Specifically, participants were contacted via
email to ask for participation, and were prompted to complete
a baseline assessment survey if they provided consent to
participate. Once baseline data were established, participants
were directed to complete the self-paced online resilience
course. Following completion of these components, participants
were later contacted via email to complete a follow-up
assessment survey at one of the randomly assigned timepoints (3, 6 or 9 months following the ORR).
Participants
A total of 227 students enrolled in the Province of British
Columbia’s PCP certificate program delivered by the JIBC
participated in this study. Of these 227 respondents, 34
paramedic students completed all three phases of the study:
baseline assessment; self-paced online resilience course;
and follow-up assessment. Accordingly, 193 respondents
completed only the baseline assessment and did not respond
to the follow-up assessment. All participation in this study was
voluntary and thus had no impact on participants’ performance
in the PCP program.
Instrumentation
The baseline assessment incorporated measures on age,
gender and education. The Resilience Scale for Adults (RSA)
(18) is a 33-item self-report scale that measures inter- and
intra-personal protective factors believed to play an important
role in one’s adaptation to adversity. This instrument consists
of 17 positively worded items and 16 negatively worded items,
measuring five dimensions of resilience: personal strength
(10 items) – perception of oneself and one’s future; structured
style (four items) – perception of one’s level of structure and
organisation in life; social competence (six items) – perception
of one’s sociability; family cohesion (six items) – perception
of one’s level of connection to their family; social resources
(seven items) – perception of one’s access to support from
friends/family members. All items on the RSA are scored

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Australasian Journal of Paramedicine: 2020;17

according to a 5-point Likert scale (ranging from 1 to 5). The full
RSA scale, along with its subscales, are created by reversecoding negatively worded items and summing across pertinent
items. Possible range for the full RSA scale is from 33 to 165,
with higher scores indicative of greater perceived resilience.
With respect to psychometric properties, Windle et al (19)
ranked the 33-item RSA (18) highly on reliability and validity.
Procedures
The researcher team randomly assigned classes to three
separate study cohorts based on when they would receive
the follow-up assessment: 3 months after completing the
ORR, 6 months after completing the ORR, or 9 months after
completing the ORR. All communication for baseline and
follow-up survey data collection was conducted through
Qualtrics (a secure platform for distributing online surveys
and storing data). The baseline assessment survey included
questions on sociodemographic characteristics (eg. age,
gender, education), as well as the instrument used to measure
resilience (the RSA). At the end of the baseline assessment
survey, participants were provided a link to the online resilience
course and were directed to complete the course at their
own pace (the course is estimated to take approximately 6–8
hours to complete). A certificate of completion was awarded to
participants who completed all learning modules in the ORR.
Depending on their randomly assigned cohort, participants who
completed the baseline assessment survey and the ORR were
contacted via Qualtrics at either 3, 6 or 9-month intervals to
participate in the follow-up assessment survey. The follow-up
survey included only the measure of resilience (the RSA).
Outcome
This study investigated whether, after having completed a
self-paced online resilience course (17), paramedic students’
scores on a measure of personal resilience would increase or
decrease between the baseline and the 3, 6 or 9-month followup assessments.

Data analysis
The Statistical Package for the Social Sciences (Version 25)
was used to clean the data and conduct all statistical analyses.
A missing values analysis was conducted on the RSA, showing
that data were missing completely at random at the baseline
(Little’s MCAR, X2 (2680) = 2644.27, p=0.685) and follow up
(Little’s MCAR, X2 (277) = 257.31, p=0.796) assessments.
Given our small analytic sample (n=34) and Little’s MCAR test
was not statistically significant, we opted to use data imputation
methods to handle missing data on RSA items as opposed to
deleting cases with missing values. Specifically, expectationmaximisation data imputation was used to handle missing
cases. The RSA scale and subscales were created after data
imputation.
With respect to descriptive statistics, analyses were conducted

on sociodemographic characteristics, stratified according to
whether or not respondents completed all three phases of the
study (responders; n=34) and those who completed only the
first phase of the study (non-responders; n=193); chi-square
test for independence and independent samples t-test were
used to compare these two groups on sociodemographic
characteristics (Table 1). Descriptive and reliability statistics
are also provided for the RSA (Table 2). Paired samples t-tests
were conducted to examine change, if any, in RSA score
from baseline to follow-up assessment for the total subset
of respondents who completed all three phases of the study
(n=34), as well as according to individual study cohort (Table
3).

Ethics
This study received ethical approval (JIBCER-2016-11-BREP)
from the Research Ethics Board at JIBC.

Results
Sociodemographic characteristics were stratified according to
the subset of respondents who completed all three phases of
the study. As shown in Table 1, responders were, on average,
older than non-responders; nearly two-thirds of responders
were female, whereas a greater proportion of non-responders
were male; and responders had a higher level of education
than non-responders.
Descriptive and reliability statistics for the RSA at baseline and
follow-up assessments are reported in Table 2. Among those
who completed the baseline assessment (n=227), baseline
scores on the RSA ranged from 79 to 162 with a mean of
127.54 (SD=15.95; 95% CI: 125–130) and internal consistency
reliability was excellent (Cronbach’s α=0.900). Among the
subset who completed all three phases of the study (n=34),
baseline scores on the RSA ranged from 94 to 156 with a
mean of 126.38 (SD=14.40; 95% CI: 122–131) and internal
consistency reliability was good (Cronbach’s α=0.878). An
independent samples t-test revealed that responders (n=34;
M=126.38, SD=14.40; 95% CI: 122–131) and non-responders
(n=193; M=127.75, SD=16.24; 95% CI: 125–130) did not
significantly differ on baseline RSA score, t (225) = 0.460,
p=0.646. Furthermore, among the subset who completed all
three phases of the study (n=34), follow-up scores on the RSA
ranged from 89 to 156 with a mean of 121.73 (SD=16.36; 95%
CI: 116–127) and internal consistency reliability was excellent
(Cronbach’s α=0.912).
Table 3 reports findings for paired samples t-tests, comparing
RSA scores at baseline to follow-up assessment for the total
subset of respondents who completed all three phases of the
study (n=34), along with the individual 3-month (n=8), 6-month
(n=20), and 9-month (n=6) study cohorts. For the total subset
of paramedic students who completed all three phases of the

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Table 1. Sample characteristics
Respondersa
(n=34)
M (SD) or %
29.52 (9.60)

Non-respondersb
(n=193)
M (SD) or %
27.02 (7.28)

Test-statisticc

Age
1.760 (p<.10)
Gender
6.400 (p<.05)
Male
32.4
52.3
Female
64.7
47.2
Education
9.160 (p<.05)
High school
5.9
20.2
Some college/institute/university
29.4
40.4
College certificate/diploma
38.2
20.7
Bachelor’s degree
20.6
14.5
Other
5.9
4.1
a
b
Participants who provided data both before and after using the ORR; participants who provided data only before using the ORR;
c
chi-square test for independence and independent samples t-test, comparing responders to non-responders on sociodemographic
characteristics
Table 2. Means, standard deviations and reliability for total RSA and RSA subscales by baseline and follow-up data collection
period
Possible range Actual range
n
Mean (SD)
Cronbach’s α No. of items
Time 1a,b
RSA

227
33-165

79-162

127.54 (15.95)

.900

33

Personal strength

10-50

24-50

39.58 (5.52)

.801

10

Structured style

4-20

5-20

14.16 (2.87)

.647

4

Social competence

6-30

9-30

21.91 (4.37)

.788

6

Family cohesion

6-30

8-30

21.95 (5.18)

.872

6

Social resources

7-35

15-35

29.92 (4.33)

.812

7

89-156

121.73 (16.36)

.912

Personal strength

25-49

37.00 (6.33)

.870

Structured style

9-19

13.88 (2.64)

.527

Social competence

9-28

20.85 (4.38)

.802

Family cohesion

9-30

21.64 (5.48)

.917

21-35

28.35 (3.69)

.787

Time 2a,b

34

RSA

Social resources

RSA = Resilience Scale for Adults; Time 1 is RSA score before using the ORR, Time 2 is RSA score after using the ORR; bTime
1 consists of responders and non-responders, Time 2 consists only of responders
a

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study (n=34), results suggest that mean RSA score decreased
by 4.64 (95% CI: -8.06 to -1.23) from baseline (M=126.38,
SD=14.40; 95% CI: 122–131) to follow-up assessment
(M=121.73, SD=16.36; 95% CI: 116–127). A paired samples
t-test revealed that the change in mean RSA score from
baseline to follow-up assessment for this subset of respondents
was statistically significant, t (33) = -2.769, p=.009. The eta
squared statistic (0.188) indicated a large effect size. Although
these results suggest that, for the total subset of respondents
who completed all three phases of the study (n=34), there is a
downward trend in mean RSA score from baseline to follow-up
assessment, further stratifying this group according to individual
study cohort reveals a somewhat different pattern.
For the subset of paramedic students assigned to receive the
follow-up assessment 3 months after completing the ORR
(n=8), findings suggest that mean RSA score increased by 3.75
(95% CI: -2.43 to 9.93) from baseline (M=128.25, SD=17.67;
95% CI: 116–140) to follow-up assessment (M=132.00,
SD=19.92; 95% CI: 118–146). However, a paired samples t-test
revealed that the change in mean RSA score from baseline
to follow-up assessment for this subset of respondents was
not statistically significant, t (7) = 1.433, p=.195. For the
subset of paramedic students assigned to receive the followup assessment 6 months after completing the ORR (n=20),
findings suggest that mean RSA scored decreased by 6.65
(95% CI: -11.22 to -2.07) from baseline (M=127.95, SD=13.63;
95% CI: 122–134) to follow-up assessment (M=121.30,
SD=13.23; 95% CI: 116–127). A paired samples t-test revealed
that the change in mean RSA score from baseline to follow-up
assessment for this subset of respondents was statistically
significant, t (19) = -3.040, p=.007. The eta squared statistic
(0.327) indicated a large effect size. Finally, for the subset
of paramedic students assigned to receive the follow-up
assessment 9 months after completing the ORR (n=6), findings
suggest that mean RSA score decreased by 9.16 (95% CI:

-15.65 to -2.68) from baseline (M=118.66, SD=11.75; 95% CI:
109–128) to follow-up assessment (M=109.50, SD=13.99; 95%
CI: 98–121). A paired samples t-test revealed that the change
in mean RSA score from baseline to follow-up assessment for
this subset of respondents was statistically significant, t (5) =
-3.635, p=.015. The eta squared statistic (0.725) indicated a
large effect size.
Figure 1a and 1b further illustrate the patterns reported in Table
3. Figure 1a shows that the 3-month and 6-month study cohort
reported a similar mean RSA score at baseline, whereas the
9-month study cohort reported a slightly lower mean RSA score
at baseline compared to these two cohorts. When comparing
Figure 1a and 1b, the mean RSA score increases between
baseline to follow-up assessment for the 3-month study cohort,
whereas mean RSA score decreases between baseline and
follow-up assessment for the 6-month and 9-month cohorts.
Figure 1b further shows that, in general, the 3-month study
cohort reported the highest mean RSA score at follow-up,
followed by the 6-month cohort and 9-month cohort.

Discussion
The results from this study suggest that the ORR may be
an effective strategy for building personal resilience among
paramedic students in the short-term. However, much like
previous research that highlights a significant skill decay
after 90 days for training in healthcare contexts (20,21), the
diminished impact of the ORR over time was also illustrated
in this study. . In addition, it is noteworthy to highlight that
the decrease in mean scores on the RSA was larger for the
9-month compared to the 6-month study cohort. Although these
findings are only preliminary, stakeholders should acknowledge
that it may be important to establish guidelines for refreshing
resilience-based skills among PSP. Perhaps it would be most
beneficial to ensure PSP are consistently exposed to resilience-

Table 3. Paired samples t-tests comparing RSA scores before and after completing the ORR, by full analytic subgroup and
individual study cohort
Paired samples test
95% CI
Cohort

Mean (SD)

Mean
difference
-4.64

t-value

p-value

Lower bound

Upper bound

Time 1
Full
126.38 (14.40)
-2.769
.009
-8.06
-1.23
a
Time 2
Subgroup
121.73 (16.36)
b
Time 1
3-month
128.25 (17.67)
3.75
1.433
.195
-2.43
9.93
Time 2
132.00 (19.92)
c
Time 1
6-month
127.95 (13.63)
-6.65
-3.040
.007
-11.22
-2.07
Time 2
121.30 (13.23)
d
Time 1
9-month
118.66 (11.75)
-9.16
-3.635
.015
-15.65
-2.68
Time 2
109.50 (13.99)
RSA = Resilience Scale for Adults; Time 1 is RSA score before using the ORR; Time 2 is RSA score after using the ORR; aN=34;
b
n=8; cn=20; dn=6

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Australasian Journal of Paramedicine: 2020;17

Figure 1a. RSA score before completing ORR (with 95% CI)

Figure 1b. RSA score after completing ORR (with 95% CI)

building strategies (eg. over 3 or 6-month intervals) following
initial involvement in a resilience training program. Such
practices would allow for these professionals to draw on
resilience-building techniques if they desire.
In addition, more general recommendations for research and
current practice may be extracted from the current study. First,
EMT/paramedic programs should consider implementing
mandatory resilience training services/programs to better help
professionals manage exposure to potentially traumatic and
stressful work-related events. In this case, a 6 to 8-hour selfpaced online resilience course may be enough for improving
personal resilience in the short-term. Further research will need
to identify an appropriate time interval for refreshing resiliencebased skills following initial involvement in a resilience training
service/program.
Researchers should also continue to investigate the
effectiveness of online educational tools, such as the ORR (17),

among varying PSP working in the field as well as students in
educational/training programs for varying types of public health
and safety professions. Continued focus on online educational
tools designed for building personal resilience, enhancing
mental wellness and psychological readiness among those
working in trauma-exposed fields is imperative, especially given
that this method of delivery increases accessibility to PSP
who may experience challenges in accessing such resources
(eg. those located in remote or rural communities and/or
completing their education online). Finally, given that several
studies have reported that a considerable proportion of EMTs/
paramedics experience mental health issues and struggle with
suicidal thoughts and behaviour (2,5-7), it is recommended that
educational tools for building personal resilience among this
group of PSP provide psychoeducation, especially with respect
to trauma or stressor-related disorders (eg. PTSI), mood
disorders (eg. anxiety and depression) and suicidal thoughts
and behaviour.

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Limitations

There are several limitations that must be considered when
interpreting the findings from this study. First, attrition is a
common issue with longitudinal study designs. Relatedly, it is
plausible that findings are somewhat biased as participants
who responded to the follow-up assessments may differ in
some respects from those who did not. In this case, it is clear
that responders and non-responders significantly differed on
some sociodemographic characteristics; however, analyses
also showed that responders and non-responders did not
significantly differ on baseline assessment of resilience.
Second, the analytic sample size (n=34) was quite small,
especially when further disaggregated by individual study
cohort; for instance, the 3-month and 9-month study cohorts
comprised of eight and six participants, respectively. Such a
small analytic sample size limits the power of inferential tests,
as well as limits generalisability and validity of the findings.
Collecting data on PCP participants at 3, 6 or 9 months after
ORR completion was particularly challenging as the participants
had graduated from the program at that point in time and
were no longer students. There are a range of methods to
improve retention for longitudinal studies, particularly for webdelivered training for student paramedics who are likely to be
bombarded with new information in their studies. Financial
compensation may have been effective at increasing response
rates as perhaps the addition of a paper-based version of the
questionnaire.
Third, there are some limitations related to the instrument
used to capture participants’ level of personal resilience (ie.
the RSA). Although it is understood that a higher score on
the RSA is indicative of a greater level of resilience, the scale
does not have ‘cut-off’ points which could aid in interpretation
of the score (eg. ‘cut-off’ points for low, medium or high
resilience). Fourth, the current study did not control for potential
confounding effects that may also explain why scores changed
between baseline and follow-up assessment. Specifically, it
is unclear whether improvement or deterioration in personal
resilience is due to a true change in skill over time or if this
change is related to exposure to other factors between baseline
and follow-up assessment.

Conclusion
This study presents evidence to suggest that an educational
tool, such as a self-paced ORR, may be an effective strategy
for improving short-term personal resilience among PCP
students. This study also presents evidence to suggest that any
improvement in personal resilience following initial involvement
in a resilience training service/program may decay over time.
Although the present findings support the use of proactive
training programs to build resilience among paramedic
students, as well as the need to consider refresher practices
to prevent skill decay, further research is required to identify

whether the skills acquired through resilience training are
effective when put into practice (eg. identifying whether PSP
with resilience training are less likely to develop PTSI related
to exposure to potentially traumatic and stressful work-related
events).

Acknowledgements
The authors would like to thank the faculty, staff and students
in the Health Sciences Division at the Justice Institute of
British Columbia (JIBC) for their interest in and support for this
research. GSA was the Dean, Office of Applied Research and
Graduate Studies at the JIBC during this project. This work
was supported by the Centre for Prevention and Reduction of
Violence at JIBC and the British Columbia Ministry of Advanced
Education.

Competing interests
The authors delare no competing interests. Each author of this
paper has completed the ICMJE conflict of interest statement.

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