Author Details
Colin Horwell and Suzanne McLaren
School of Behavioural & Social Sciences & Humanities
University of Ballarat, Australia
 

Introduction
The mental health of people residing in rural areas has increasingly become a cause of concern.  Research has indicated that rural residents are more likely to suffer from stress (Hays & Zouari, 1995; Johnson, 1998; Marsella, 1998), depression (Cheng, Soong, Chong, & Lin, 1995; Hays & Zouari, 1995; Zimbelman, 1987), psychiatric illness (Lawrence & Williams, 1990; Mumford, Saeed, Ahmad, Latif & Mubbashar, 1997; Wagenfeld, 1982), and alcohol dependence and abuse (Lee et al., 1990).  In addition, a substantial increase in the incidence of suicide in rural areas has been documented (Coleman, 1995; Dudley, Waters, Kelk, & Howard, 1992; Lohse, 1992; Pritchard, 1992).  Whereas the effects of living in a rural area have been investigated, relatively little research has investigated the effects of working in rural areas.  It may be expected that people working in an occupation identified as high stress who live in a rural environment may experience more stress than people working in the same occupation and living in an urban environment.  A survey of physician assistants in the United States who practice in rural areas demonstrated a high level of job satisfaction (Muus et al., 1998).  Other research has noted the unexpected low levels of stress in correctional officers working in rural Canada (Pollak & Sigler, 1998).  Comparative studies of workers in rural and urban settings are rare.  A study investigating stress in ambulance officers reported that place of residence (rural/urban) did not moderate the experience of stress (James, 1988).  A recent Australian study surveyed social workers who were employed in rural (n = 56) and metropolitan (n = 184) locations (Dollard, Winefield, & Winefield, 1999).  Results indicated no differences between the two groups of workers on measures of job satisfaction, physical health symptoms, and burnout.  Such results are in contrast to the general literature that suggests that living in rural areas is associated with elevated stress.  It may be that other factors such as coping are important.  Overall, it may be concluded that very little is known about people employed in particular occupations and who work in rural or urban locations.  This study focused on ambulance officers working from rural and urban stations in the state of Victoria, Australia.

The work of an ambulance officer, or paramedic, has been identified as highly stressful (Grevin, 1996; James, 1988; Marmar, Weiss, Metsler, Ronfeldt, & Foreman, 1996).  As an occupational group, ambulance officers are confronted with life and death medical emergencies, are repeatedly exposed to human tragedy, and are pressured to perform in uncertain, often hazardous situations (Goldstein, Jamner, & Shapiro, 1992).  Further, ambulance officers are frustrated by organisational and administrative functions.  They are underpaid, have low decision making latitude, excessive paper work and little support (Goldstein et al., 1992; James, 1988).

Overall, a paucity of research has examined stress and coping in ambulance officers.  The focus of existing research has been disaster situations and post-traumatic stress disorder (Harkins, 1996; Marmar et al., 1996; Werner, Bates, Bell, Murdoch, & Robinson, 1992).  Many other aspects of the stress process, including coping, have been neglected.

One of the key factors in combating stress, is the existence of coping resources (Hammer, 1988).  Coping resources have been defined as “relatively stable dispositional characteristics that affect the coping process” (Moos & Billings, 1982, p. 215).  Resources such as self-esteem and self-efficacy (Avison & Gotlib, 1994), self-confidence (Callan, Terry, & Schweitzer, 1994), mastery (Begley & Boyd, 1992), and one’s cognitions and perceptions (Pearlin & Schooler, 1978) and beliefs (Lazarus & Folkman, 1984) have been related to lower stress.  A sense of physical well-being (Long & Flood, 1993) and a belief in higher powers (Hammer, 1988) have also been related to lower stress.

Coping resources can also be external to the individual.  In an occupational setting, social resources include socio-emotional support, availability of information, tangible forms of aid and support from supervisors (Shaw, Fields, Thacker, & Fisher, 1993).  The most often researched is social support.  Perceptions of social support have been consistently related to lower stress (Geller & Hobfoll, 1994; Manlove, 1994; Schauben & Frazier, 1995).  Research has demonstrated that workers were more likely to use social support systems if they perceived the work organisation to be supportive (Jayaratne, Himle, & Chess, 1988; Yang & Carayon, 1995).  A study of stress in office workers indicated that supervisor support was associated with a greater reduction of worker stress than support from co-workers (Yang & Carayon, 1995).

There is substantial evidence to suggest that coping resources, both inherent and external, are related to reduced stress.  The quantity and quality of resources available to workers may be particularly important given that individual coping strategies have been demonstrated to be ineffective in ameliorating the effects of work stress (Pearlin & Schooler, 1978; Shinn, Rosario, Morch, & Chestnut, 1984).  It would appear important therefore to examine the coping resources available to ambulance officers.

There is evidence to suggest that coping resources vary as a function of place of residence.  Research has indicated that urban residents received more social support and utilised cognitive resources more frequently than rural residents (Amato, 1993; Lin & Rogerson, 1995; Wenger, 1995; Wood & Parham, 1990).  Further, urban people rely on religion more often than rural people (Wood & Parham, 1990) although this resource has shown conflicting results (Kovess, Murphy, & Tousignant, 1987).  Previous research has rarely investigated coping resources other than social support and religion.

The current research aimed to compare stress and coping in ambulance officers working in rural locations to their colleagues working in more populated areas.  It was anticipated that ambulance officers working in a rural setting would report higher levels of stress than their colleagues working in an urban setting.  It was also expected that urban officers would report more social and spiritual/philosophical resources than rural ambulance officers.

Method

Participants
All ambulance officers in the Western and North-Western regions of Ambulance Service Victoria, Australia, were sent a questionnaire package.  A total of 102 questionnaires were returned (51.5% response rate).  The responses of four females were eliminated due to small sample size.  The remaining responses of the males were divided in to two groups.  The “urban” group referred to ambulance officers who worked from stations attached to regional headquarters.  Such ambulance stations are located in heavily populated areas of the state of Victoria (50,000 to 80,000 residents).  The remaining ambulance officers worked at stations in less populated, rural locations (“rural”).

 The 46 urban officers (mean age = 40.85 years, SD = 7.10) had been in the service an average of 15.43 years (SD = 5.98) and had been in their current position 10.22 years (SD = 6.87).  The 52 rural officers (mean age = 42.62 years, SD = 6.60) had been employed in the service an average 16.00 years (SD = 7.23) and had been in their current position 9.06 years (SD = 6.21).  There were no differences between the two groups on age, t(96) = 1.28, p > .05, years in the service, t(96) = 0.42, p > .05, or years in current position, t(96) = 0.88, p >.05.
 The majority of the sample (86%) was married and had completed secondary school (70%).  A smaller number had also completed a technical qualification (41%).  The profiles of the two groups were very similar in regard to marital status and education.

Measures
The Perceived Stress Scale (Cohen, Kamarck, & Mermelstein, 1983) was used to assess stress levels.  The 14-item scale consists of questions concerning the participant’s feelings and thoughts in the previous month, and the participant was required to respond using a 5 point likert scale (0 = never, 4 = very often).  Higher scores reflect higher levels of stress.  Previous research using this scale has found it to be reliable (alpha = .85) (Cohen et al., 1983).

The Coping Resources Inventory (Hammer, 1988) is a 60-item scale that assesses the range of inherent and external coping resources available to each participant.  The scale consists of five subscales: cognitive resources (positive feelings towards oneself and others, and a general optimistic attitude); social resources (the social support network of the individual); emotional resources (the individual’s acceptance and expression of affect); spiritual/philosophical resources (religious, familial, cultural and personal philosophies); and physical resources (the extent to which the individual engaged in health promoting behaviours).  Cronbach’s alpha coefficients for each subscale were as follows: Cognitive alpha = .77, Social alpha = .79, Emotional alpha = .84, Physical alpha = .71 and Spiritual/Philosophical alpha = .80 (Hammer, 1988).

Procedure
A questionnaire package consisting of the Perceived Stress Scale and the Coping Resources Inventory, in addition to a covering letter, was mailed to every serving officer in two regions of the state of Victoria, Australia.  Completed questionnaires were returned in reply-paid envelopes to the researchers.

Results

Reliability Coefficients
Reliability coefficients were calculated for the Perceived Stress Scale, and for each of the subscales of the Coping Resources Inventory.  Results indicated satisfactory internal reliability: Perceived Stress Scale alpha = .84, Emotional Subscale alpha = . 86, Spiritual/Philosophical Subscale alpha = .69, Physical Subscale alpha = .77, Cognitive Subscale alpha = .75, and Social Subscale alpha = .84.

Rural-Urban comparisons
The means and standard deviations for both groups for each dependent variable can be seen in Table 1.  A one-way multivariate analysis of variance demonstrated no differences between the rural and urban officers on coping resources, F(5, 92) = 1.61, p > .05, although the univariate analyses indicated that there was a distinct trend for rural officers to report more social support than urban officers, F(1, 92) = 5.25, p < .03.

A one-way analysis of variance indicated that the rural ambulance officers did not report higher levels of perceived stress than the urban ambulance officers, F(1, 96) = 1.07, p >.05.

Comparison to normative data
A series of independent sample t-tests were conducted to test for differences between the ambulance officers and normative data on the coping resources and stress measures.  The means and standard deviations can be seen in Table 2.  Results indicated that the ambulance officers reported significantly lower stress levels than the combined normative samples reported by Cohen et al. (1983).  They also possessed more social resources and fewer spiritual/philosophical coping resources than the normative sample reported by Hammer (1988).

Coping resources
A one-way repeated-measures analysis of variance was conducted to test for differences between the different types of coping resources possessed by the ambulance officers.  In order to conduct this analysis, raw scores were converted to standard scores, as reported by Hammer (1988).  Mean standard scores for each coping resource, for the whole sample, can be seen in Table 3.

 Results indicated that the ambulance officers reported different levels of the coping resources, F(4, 94) = 17.69, p < .001.  Paired samples t-tests were conducted to test for differences between the coping resources.  Social support was reported more frequently than physical, t(97) = 3.23, p < .001, cognitive, t(97) = 4.46, p < .001, emotional, t(97) = 7.87, p < .001, and spiritual/philosophical resources, t(97) = 6.89, p < .001.  Physical resources were reported more often than emotional, t(97) = 3.83, p < .001, and spiritual/philosophical resources, t(97) = 3.16, p < .01.  Similarly, cognitive resources were reported more often than emotional, t(97) = 4.62, p < .001, and spiritual/philosophical resources, t(97) = 3.65, p < .001.  Thus, social resources were reported most often, whereas emotional and spiritual/philosophical resources were reported least often.

Coping resources and stress
A series of correlations were conducted to test for relationships between each coping resource and stress.  The correlations can be seen in Table 4.  Results indicated that stress was negatively correlated with each of the coping resources.

Discussion
The current research aimed to document the coping resources and stress levels of ambulance officers working in rural and urban environs.  The results from the comparisons between the urban and rural officers were not as predicted.  It was expected that working as an ambulance officer in rural Australia would be associated with higher levels of stress than working in the same occupation in urban Australia.  No difference was demonstrated between the two groups of ambulance officers in the experience of perceived stress.  This is the third comparative study to demonstrate that rural/urban residence is not associated with the reporting of stress (see Dollard et al., 1999; James, 1988).  Other research has demonstrated that correctional officers in rural Canada had low levels of stress (Pollak & Sigler, 1998) and that physician assistants living in rural areas within the United States had high levels of job satisfaction (Muus et al., 1998).  Such findings are in contrast to what was expected in the research, as well as research documenting high levels of stress (Hays & Zouari, 1995; Johnson, 1998; Marsella, 1998), depression (Cheng et al., 1995; Hays & Zouari, 1995; Zimbelman, 1987), psychiatric illness (Lawrence & Williams, 1990; Mumford et al., 1997; Wagenfeld, 1982), alcohol dependence and abuse (Lee et al., 1990) and suicide (Coleman, 1995; Dudley et al., 1992; Lohse, 1992; Pritchard, 1992) in rural residents.  It is to be noted that the current research did not investigate possible differences in sources of stress between ambulance officers working in differentially populated areas.  An Australian study investigating strain in social workers demonstrated different predictors of strain for those who worked in rural locations compared to their metropolitan counterparts (Dollard et al., 1999).   For rural social workers, strain was predicted by work role ambiguity and the perception of unfair selection processes.  For metropolitan workers, the best predictors of strain were poor peer cohesion and work role ambiguity. This research suggests that different models of stress exist according to where one lives and works.  Such differences should be the focus of future research.  The lack of differences in stress levels between rural and urban workers in this study may be attributable to differences in factors such as coping.

When the coping resources reported by the ambulance officers were examined as a function of residence, an overall difference was not detected.  Inspection of the individual subscales indicated that rural officers reported the availability of more social support.  This was unexpected, as previous research had shown urban dwellers to receive more social support.  Further, such research had also shown urban residents to utilise cognitive resources and religion more frequently than rural residents (Amato, 1993; Lin & Rogerson, 1995; Wenger, 1995; Wood & Parham, 1990).  Thus, the current results are inconsistent with previous research which has documented differences in coping as a function of residence (Amato, 1993; Kovess et al., 1987; Lin & Rogerson, 1995; Wenger, 1995; Wood & Parham, 1990).

Ambulance officers living in rural settings, away from the major headquarters, had more social support available to them than those working in urban settings, and who were, therefore, physically closer to management.  This result may be related to the working environment, as research has documented the ambulance organisation, including those in administrative positions, to be unsupportive of officers (Goldstein et al., 1992; James, 1988).  As previously noted, a supportive organisation enhances the use of social support by employees (Jayaratne et al., 1988; Yang & Carayon, 1995).  Future research should investigate a possible link between the ambulance organisation and the perception and use of social support by ambulance officers.

The results indicated that urban and rural ambulance officers experience similar levels of stress and coping resources.  Place of residence was therefore not considered in the remaining discussion of the coping resources possessed by these ambulance officers.  The ambulance officers reported having social support available to them.  In fact, they reported the availability of social support to a greater extent than the normative sample reported by Hammer (1988).  This is a positive finding, given that social support has so often been associated with lower stress (e.g., Geller & Hobfoll, 1994; Manlove, 1994; Schauben & Frazier, 1995).  Social support is seen to reduce stress through a variety of direct and indirect ways, including providing self-reliance and the ability to persevere during difficult times (Sarason, Sevine, Basham, & Sarason, 1983).  The possession of many social support resources is also reassuring, given that social support has been found to be more effective in work situations than individual coping efforts (Shinn et al., 1984).  It should be noted that the reporting of social support is not the same as utilising that support when stressed.  However, researchers have documented that the likelihood that one uses social support is dependent upon one perceiving the support to be available (Jayarante et al., 1988).  Indeed, the actual perception of support is one of the most effective resources in combating stress (Coleman, Iso, & Seppo, 1993).

Results also indicated that ambulance officers perceive themselves as having considerable physical and cognitive resources.  The current sample reported a similar level of these types of resources to Hammer’s (1988) normative sample.  Physical resources relate to the health-promoting behaviours that are believed to contribute to physical well-being (Hammer, 1988).  Physical well-being in turn, can limit chronic stress resulting from the presence of physical symptoms (Hammer, 1988).  Much research has documented the benefits of exercise in reducing stress and enhancing mood state (e.g., Boutcher & Landers, 1988; Kerr & Van Den Wollenberg, 1997; Long & Flood, 1993; Steptoe, Kimbell, & Basford, 1998).

Cognitive resources include problem-solving ability and intellectual processes that serve to maintain a sense of self-worth and a positive outlook on life (Hammer, 1988).  Cognitive resources may buffer the impact of stress by controlling the meaning of the problem (Lazarus & Folkman, 1984).  Those with adequate cognitive resources feel adequate to cope with life’s stressors, persist in their coping efforts and achieve adaptation (Terry, 1992).
 The ambulance officers reported fewer emotional and spiritual/philosophical resources.  Emotional coping resources refer to an individual’s ability to accept and express affect, with such acceptance and expression improving long term adaptation to stress (Hammer, 1988).  There is evidence to suggest that some individuals do not express their emotions because they associate such behaviour with weakness (Joseph, Yule, Williams, & Hodgkinson, 1994).  Further, the inhibition of emotional expression because of such cognitions is associated with psychological distress (Joseph et al., 1994).

Spiritual/philosophical coping resources were the fewest reported by the ambulance officers.  Indeed, they reported significantly fewer spiritual/philosophical resources than the normative sample reported by Hammer (1988).  These resources reflect values of the individual; values which are stable, and are derived from religious, familial or cultural tradition, or from personal philosophy (Hammer, 1988).  These resources are valuable because they help to define experiences in a positive light and prescribe strategies for responding effectively (Lazarus & Folkman, 1984).  As a group however, these resources are the fewest possessed.  Research documenting coping resources of emergency workers attending a disaster scene found about 25% of respondents turn to religious beliefs or other personal philosophies on life in order to cope (Miles, Demi, & Mostyn-Acker, 1984).  A minority of people may possess such resources, but those who report their existence call on such resources during stress.

The stress levels of the ambulance officers were significantly lower than the sample reported by Cohen et al. (1983).  This is surprising, given the research that has identified this occupation to be stressful (Grevin, 1996; James, 1988; Marmar et al., 1996). Indeed, such officers have similar stress levels to police officers and correctional officers (McLaren, Gollan, & Horwell, 1998).  The current sample was not highly stressed, and was not more stressed than the normal population.

The low stress levels, especially among the rural officers, are in contrast to the perception that rural life is related to stress as previously documented.  One may propose that the high level of coping resources reported by the sample, with the exception of spiritual/philosophical resources, is related to this low stress level.  Indeed, the correlations between stress and the coping resources were all in the expected direction.  The perception of having each resource available was significantly related to lower stress.  These results confirm the beneficial nature of coping resources.

The self-report nature of the study, along with the cross-sectional design, are noted as limitations of the current research.  When using multiple self-report measures, there is the possibility of obtaining significant correlations between constructs due to overlap between the items of each measure.  Close examination of the Perceived Stress Scale (Cohen et al., 1983) and the Coping Resources Inventory (Hammer, 1989) indicated that there was very little, if any overlap between the two measures.  Consequently, one may be confident that the significant correlations between stress and each of the coping resources are not due to shared variance between the self-report measures.  To avoid issues such as common method variance, it has been recognized that researchers should utilise multi-dimensional methods to investigate stress including psychophysiological indices (Balick & Herd, 1987; O’Keeffe & Baum, 1990).  The practicalities, however, of employing such measures in terms of time, expense and sample size, can preclude or limit their use.

Overall, the results have shown this sample of urban and rural ambulance officers to possess satisfactory levels of coping resources, as compared to normative data, and to report low levels of stress.  The coping resources possessed by the officers were all related to lower stress levels.  Results suggest that bolstering individuals’ coping resources may assist in minimising stress.  Results also showed no differences in stress and most coping resources as a function of living and working in differentially populated areas.  As suggested, future research may further investigate the unexpected difference in social support, with the focus being on the possible role of the ambulance organisation.

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