Personnel who work in emergency medical services (EMS) face work environments which are high stress. These can lead to burnout, secondary traumatic stress (STS), and a reduction of compassion satisfaction (CS). However, very little is known about what individual and work factors influence these negative coping mechanisms in EMS personnel. It is also unknown how perceived organizational and coworker support, debriefing methods, or individual characteristics are associated with the aforementioned coping mechanisms in EMS personnel. The paper aims to discuss these issues.
A cross-sectional administration of surveys to Florida EMS personnel was done. A total of 351 individuals who regularly performed EMS tasks completed the survey. Three regression analyses were carried out, utilizing the three ProQOL 5 subscales as the dependent variables. The Perceived Coworker Support survey, Survey of Perceived Organizational Support, the Brief Resilience Survey and questions regarding debriefing practices were included.
Both organizational support and psychological resilience were found to be related to higher CS as well as lower burnout and STS. Coworker support was associated with higher CS. Informal debriefing was associated with higher CS and lower burnout. Several individual factors were also statistically significant, specifically education with CS, being a volunteer and race with burnout, and working part time or volunteering with STS.
There are limitations due to the nature of cross-sectional survey design and due to the sample size. The varying circumstances which EMS personnel work also hinders generalizability.
This study displays statistical relationships between factors which EMS agencies could use to increase employee job satisfaction and potentially reduce turnover.
Miller, A., Unruh, L., Liu, X., Wharton, T. and Zhang, N. (2018), "Individual and organizations factors associated with professional quality of life in Florida EMS personnel", International Journal of Emergency Services, Vol. 7 No. 2, pp. 147-160. https://doi.org/10.1108/IJES-08-2017-0041Download as .RIS
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Emergency medical services (EMS) employees serve a vital safety net function for society. Yet the job, by its very nature can be very traumatic. EMS personnel have been documented as having higher than average exposure to traumatized individuals than the general population (Beaton et al., 1998). First responders often complain about their work environment including lack of organizational resources (Edwards et al., 2008) and lack of organizational support (Vagg and Spielberger, 1998). Poor communication with the organization was associated with higher levels of traumatic stress symptoms in EMS personnel, as was low levels of coworker support (Van Der Ploeg and Kleber, 2003). The stresses of the job combined with work environment factors can lead to turnover and/or negative mental health outcomes of EMS personnel. Given the vital role EMS personnel play in public health and in public safety, it is simply unacceptable that so little attention has been paid to their mental health.
This study, which was part of a dissertation study with a focus on organizational policy, utilized the constructivist self-development theory (CSDT) as its foundation. CSDT focuses on the influences that a person’s developmental, social, and cultural contexts have on how they perceive and interact with the world. The theory explains the aspects of the “self” that are affected by traumatic events and how people can have positive feelings of compassion satisfaction (CS), or negative ones of burnout and secondary traumatic stress (STS), when working with traumatized individuals. The balance of these positive and negative feelings is helpful in understanding professional quality of life. The theory portrays the individual’s response and adaptation to trauma as an interaction between their “personality and personal history and the traumatic event and its context, within the social and cultural contexts for the event and its aftermath” (Saakvitne et al., 1998). There are certain psychological needs that must be met for people to be able to psychologically integrate experiences (Ryan and Deci, 2000). The ones relevant to organizations are trust/dependency, esteem, and control (McCann and Pearlman, 1990). It was hoped that by identifying corresponding factors an organization (discussed below) can influence the way in which individuals responded to trauma, that the study could provide real-world applications. It was felt by all involved that based on the literature surrounding how an organization could influence these constructs and therefore the professional quality of life as well as the practical experience of the doctoral candidate from her EMS work experience, that the best way to measure the practical application of these concepts was to examine the organizational expression of these constructs. The instruments were chosen because they were all previously used and validated. The chosen instruments as well as the literature supporting their selection and which theoretical construct they address are briefly discussed.
Burnout is a defensive coping mechanism that people develop in order to deal with psychological strain and inadequate support (personal and/or organizational) (Jenkins and Baird, 2002). EMS is a field that has a very high risk of professional burnout (Regehr and Millar, 2007), including among volunteer EMTs (Essex and Scott, 2008). The level of burnout for EMS is even higher than most of the healthcare sector and fire (Smith and Roberts, 2003). It could be related to reported low supervisory support (Halpern and Maunders, 2011). In departments where EMS is combined with fire, there are also reports of low levels of support from administration and their firefighting colleagues (Lloyd, 2004). According to CSDT, burnout development parallels other stress responses (McCann and Pearlman, 1990) and can be a predicted outcome when a person’s needs are unmet.
Perceived organizational support means that the employees feel that their socioemotional needs are met and the organization values them (Eisenberg et al., 2002). When employees feel the organization supports them, employees have higher job satisfaction (Rhoades and Eisenberger, 2002). A related concept is coworker support. People are less stressed and more satisfied when they feel supported by peers (Martin, 2010). Employees who have more coworker support have lower levels of emotional exhaustion (Halbesleben, 2006), lower intentions to turnover (Nissly et al., 2005), and higher job satisfaction (Baruch-Feldman et al., 2002). Camaraderie among EMS personnel has been found to reduce reported levels of burnout (Blau et al., 2012). This ties into both the trust/dependency and the esteem psychological needs EMS personnel have.
STS refers to the stress related symptoms which develop through secondary exposure to traumatic events. Secondary sources include pathways such as treating patients who have undergone major trauma (Bride, 2004) which is a job description for EMS. STS has recently been included as a subset of post-traumatic stress disorder (PTSD) according to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) and displays the two alternating states of numbness and overwhelming feelings indicative of PTSD. STS has been shown to be significantly related to less education (Arvay, 2001) and less training among rescue workers (Marmar et al., 1996). Unmarried EMS personnel are more susceptible to PTSD than either law enforcement or fire in one study (Berger et al., 2007), implying that individual factors also play a role in the development of negative coping mechanisms. It is established in the general public men experience potentially traumatic events more often than women but women are more likely to develop PTSD/STS symptoms (Breslau, 2009). For EMS however, evidence shows that men are more likely to display symptoms (Berger et al., 2007; Bennett et al., 2005; Bennett et al., 2004). This is one of the major possible negative impacts from working with traumatized individuals according to CSDT (McCann and Pearlman, 1990).
The psychological construct known as “Resilience” is defined as the ability of individuals to recover from negative experiences through the use of positive emotions to cope (Tugade et al., 2004). After traumatizing events, resilient individuals may experience short-term emotional dysregulation, but it tends to be short and mild enough not to significantly impede their ability to function (Bonanno et al., 2006). It is a personality aspect that can be promoted and cultivated (Tugade and Fredrickson, 2007). This implies that teaching people to manage their stress could potentially reduce STS. Resilience has been found to be negatively related to PTSD in EMS personnel (Streb et al., 2014). Resilience is positively associated with active coping and other behaviors consistent with better views of “self” (Smith et al., 2008).
Historically debriefing served tactical purposes; it was a fact-finding task (Raphael and Wilson, 2000). It evolved once it was observed there were positive emotional responses from the troops when discussing a distressing incident (Wollman, 1993). Debriefing has been used for a couple of decades among EMS (Smith and Roberts, 2003). The modern day connotation is essentially synonymous with critical incident stress debriefing (Rose et al., 2002), although it can also include informal methods, such as speaking with coworkers. However the research on formalized debriefing methods indicates its effectiveness is debatable (Hawker et al., 2011). There is some evidence that when it is voluntary it reduces trauma (Deahl, 2000) as well as burnout and compassion fatigue in EMS personnel (Halpern et al., 2012). It has been shown that the formal methods of debriefing may in fact be helpful for those who request it but harmful for those who are forced to participate (Devilly et al., 2006). Debriefing activities can increase trust with coworkers and the organization and possibly influence the sense of control personnel have (Fullerton et al., 2000).
CS and compassion fatigue are related concepts. The satisfaction a person experiences by helping people while working is known as “Compassion satisfaction” (Stamm, 2002). Whereas compassion fatigue is a possible consequence of working with traumatized individuals, wherein professionals display reduced capacities or desires to assist with the traumatic events of another person (Boscarino et al., 2004). Since empathy and compassion are the major motivating factors in a person’s desire to help others (Udipi et al., 2008), this can be very problematic when a large portion of a job requires dealing with traumatized people (Joinson, 1992). However there has been minimal research into the prevalence of compassion fatigue and CS among EMS (Regehr et al., 2002).
Purpose of the study
Although people depend on EMS personnel to serve as part of their safety net during times of crisis, there has been minimal research into the psychological toll that this work has on the personnel themselves. Given the literature and theoretical framework, this study was undertaken to provide some insight into the current state of affairs. The purpose of this study is to determine the levels of CS, burnout, and STS in Florida EMS personnel as well as to determine what individual and work environment factors are related to them. Until the current status of the situation and potentially ameliorating factors are identified EMS personnel cannot receive possibly much needed support. In order to evaluate, the following research questions were explored:
Is there a relationship between demographic characteristics and professional quality of life among Florida EMS personnel?
Is there a relationship between perceived support and professional quality of life among Florida EMS personnel?
Is there a relationship between psychological resilience and professional quality of life among Florida EMS personnel?
Is there a relationship between debriefing activities and professional quality of life among Florida EMS personnel?
This descriptive and correlational study was non-experimental and cross-sectional. A self-reported web-based survey was utilized to increase participants’ anonymity and to facilitate distribution of the survey. Prior to contacting any participants, multiple public safety professional organizations were contacted. Of the ones contacted, two organizations wrote a letter of support for the study.
This study focused on those currently working or volunteering as EMTs. To get this list of people, it was decided to contact public agencies utilizing the Florida Sunshine Laws public records requests. Given that 89.8 percent of EMS agencies in Florida were public (Centers for Disease Control, 2011), this covered most EMS personnel in Florida. There were 272 licensed EMS agencies in Florida (Florida Department of Health, 2013) and the e-mails for their EMS personnel were requested. A total of 164 locales provided professional e-mails of their employees. However, since some agencies only had a single e-mail list (such as not separating the administrative from the EMS personnel) it is unknown what the accurate response rate for the study.
The IRB of a university in Florida gave approval prior to participant contact. Between the months of November 2015 and February 2016, participants were sent an e-mail requesting their participation. The email contained a link to the survey tool through Qualtrics, as well as a message explaining the voluntary nature of the survey, informed consent, and the survey’s intention. Approximately two weeks later they received a follow-up e-mail. To be eligible for the study, the participants had to report to be currently working or volunteering as public safety personnel in the state.
The survey included four previously validated instruments as well as a separate instrument ascertaining access to debriefing after traumatic events. The Professional Quality of Life: CS and Compassion Fatigue version 5 (ProQOL 5) was used to ascertain the dependent variables of CS, burnout, and STS. It consists of self-reported responses to 30 statements utilizing a five-point Likert scale. The α reliabilities for the ProQOL 5 are very good, with a range of 0.88-0.75 for the subscales (Stamm, 2010). To establish the level of support that they perceive from an organizational level the eight item survey developed from Eisenberger’s Survey of Perceived Organizational Support (SPOS) (Eisenberger et al., 1986) was used and supplemented with the nine-item Perceived Coworker Support (PCS) instrument (Ladd and Henry, 2000). The SPOS contains right statements utilizing a seven-point Likert scale ranging from 0=Strongly Disagree to 6=Strongly Agree. To establish the individual levels of psychological resilience, the six-item Brief Resilience Survey (BRS) was used (Smith et al., 2008). To gauge debriefing activities, participants were asked to agree or disagree to participating on a variety of formal and informal debriefing behaviors. Demographic questions were also included.
A total of 351 participants who regularly completed EMS tasks completed the survey. An a priori power analysis using G×Power 3.1 (Faul et al., 2007) was conducted. In the calculation the assumed values of α=0.05, power=0.95, an effect size of 0.15, and 27 predictors were used. A minimum sample size of 249 was calculated and met. Prior to analysis the data were screened and cleaned. In order to evaluate the missing data, analysis was completed with STATA 12. The results showed that the data were not missing at random. Accordingly, no method of imputation was appropriate nor used and the cases were deleted in a case-wise fashion for analyses. After appropriate reverse coding, each scale had a score calculated through summation. These new variables became the dependent variables in the analyses. Due to the design of the ProQOL 5, the composite scores for each subscale cannot be combined, and must be used separately from each other (Bride et al., 2007). Dummy variables were created of the categorical independent and control variables, with male serving as the reference group for gender, “no” serving as the reference group for working in other fields, married was the reference group for relationship status, Caucasian was the reference group for race/ethnicity, “yes” was the reference group for the question regarding stress training, and High school diploma/GED was the reference group for educational level. For all questions on the debriefing questionnaire “yes” was the reference group. These reference groups serve as the comparison to which all the respective categorical variables are compared to in a regression. Three OLS linear multiple regressions with each subscale score serving as the dependent variable with the other instruments serving as the independent variables utilizing SPSS 25 were the primary method of statistical analysis. The questions on the demographic questionnaire served as control variables. Descriptive analysis was performed and can be seen below Table I.
The majority of the participants were male (85.2 percent), Caucasian (86 percent), and frequently perform tasks in another public safety field (92.3 percent). Most participants were married (67.2 percent), were employed full-time (98 percent), and most commonly had an Associate’s degree or technical training as their highest educational attainment (41 percent). Most reported having received some sort of stress management training through their place of employment (61.5 percent). The study sample is similar to the known demographics of the national EMS population. At the national level most EMS personnel are Caucasian (90.2-92.3 percent) and Male (71.2-69 percent) which is close to the study percentages of 86 and 85.2 percent, respectively. Although not shown on the table, the average age in the study (40.8) is slightly older than the average age of working EMS personnel nationwide (35) (NHTSA, 2008). The similarities should assist generalizability.
The correlation matrix of the scales can be found below in Table II. The scores for each survey instrument as well as the subscales of the ProQOL 5 were utilized in a two-tailed Pearson correlation. Linear relationships exist between all coefficients, which are all significant. Most of the coefficients display a moderate (0.36-0.67) correlation and no strong correlations between variables in the same regression (Taylor, 1990). The Cronbach α are also reported. The reliabilities are all around or above the thresholds the literature suggests for research of this type (Peterson, 1994).
For the regressions, only the statistically significant (p-value⩽0.05) regression coefficients will be discussed. In order to provide a more intuitive discussion of the topic, only unstandardized betas were reported. In Table III, it can be seen in the CS regression that Hispanics have more CS (an average score 3.168 higher, all else constant) than Caucasians. Those with post-graduate training reported higher levels (7.532) of CS than those with a high school degree. For every point increase in the SPOS, there was a positive improvement (0.159) in CS. There were similar positive associations with the PCS (0.271) and the BRS (0.289). Individuals who did not speak to their coworkers reported a lower level of CS (−2.738). The R2 for this regression was 0.676, meaning that the independent variables explained 67.6 percent of the variation in the CS score.
In the Burnout regression, Hispanics had less burnout (−3.389) than Caucasians. Volunteers had less burnout than those who worked full-time (−11.894). The SPOS score was negatively associated (−0.238) with burnout, meaning that every point on that survey resulted in lower levels of burnout. Psychological resilience was also negatively associated with burnout, with each additional point on the BRS resulting in a decrease of −0.438 in reported burnout. EMS personnel who did not speak to their coworkers reported higher levels of burnout (4.242). The R2 for this regression was 0.732.
In the STS regression, the employment status was associated with STS. Those who were employed part time in public safety displayed higher levels of STS (8.993) while those who volunteered showed lower levels (−15.172). The SPOS was inversely associated with STS, with each additional point on the survey being associated with a decrease in STS (−0.177). For each additional point increase in the BRS, there was also a reduction in the STS (−0.71). The R2 for this regression was 0.641.
In the CS regression there were several interesting results. The role education played with CS was complicated, with only post-graduate education showing more CS than those with a high school diploma. The literature is conflicting on the relationship between education and CS/compassion fatigue, with some evidence of no relationship (Injeyan et al., 2011) and some evidence of education protecting against compassion fatigue (Yoder, 2010). This study does not provide much clarity to the situation. Perceived organizational support has previously been associated with lower levels of compassion fatigue (Hunsaker et al., 2015). Stronger social support and better relationships with coworkers is also associated with lower levels of compassion fatigue (Ray et al., 2013), meaning that the finding of a positive association between PCS and CS is expected. This study found a positive association between psychological resilience and CS. This is in line with previous literature in which resilience has been associated with higher CS (Cooke et al., 2013). Informal debriefing was associated with increased CS. Literature shows that it is a popular method for assisting in releasing pent-up emotions (Tuckey, 2007), which this study corroborates.
In the burnout regression, two demographic items were statistically significant. Hispanic ethnicity was associated with lower burnout. This is in line with a study of emergency dispatchers showing Hispanic dispatchers displayed lower burnout than Caucasians (Miller et al., 2017). The other demographic characteristic was being a volunteer, which was associated with lower levels of burnout. Volunteers are vitally important in the EMS field in the USA, with 49.8 percent of EMT-Bs and 21.8 percent of paramedics estimated to be volunteers (Dawson et al., 2003). This study contradicts a previous study which found that volunteer EMTs were at high risk for burnout (Essex and Scott, 2008). Three other constructs were associated with burnout. The first was perceived organizational support. Perceived organizational support has been correlated with lower levels of burnout in the literature (Yaghoubi et al., 2014). This study further confirms this. The next variable was psychological resilience. Previous studies have found increased resilience is associated with less burnout (Mealer et al., 2012). There was no relationship between PCS and burnout. There was however a relationship between informal debriefing and burnout. Those who did not speak to coworkers about cases which bothered them reported higher levels of burnout. A study of Australian nurses found that nurses reported informal debriefing was a “key factor in enabling nurses to carry on with their work” (Drury et al., 2014).
In the STS regression, being a volunteer was again significant, with volunteers having less STS than full-time EMS personnel. It is possible that this is reflective of volunteers seeing traumatic incidents much less frequently or because they have different social and familial support, which could also explain the part time employees having more STS. Perceived organizational support was associated with lower STS. How a person responds to a psychologically stressful situation depends on personal attributes as well as social environment and organizational environment for professionals working to help people (Trippany et al., 2004). Resilience was also associated with lower levels of STS, which is in line with previous studies (Streb et al., 2014).
It is in an agency’s best interest to increase the professional quality of life of its employees. This study confirms that the findings of other fields can apply to EMS personnel. EMS agencies can be aware of populations which may need extra support, such as volunteers and part-time employees. Not only is turnover costly to the agency, they have the ability to influence it. This study shows that organizations can influence the professional quality of life of their staff by implementing policies increasing organizational support which would be helpful in increasing CS as well as decreasing burnout and STS. This can be done by showing fairness, supervisor support, and organizational rewards and improving job condition where possible (Eisenberger et al., 1986). Increasing supervisor support would also increase coworker support, which would also increase CS. Both burnout and intent to turnover are significantly related to lack of supervisory support (Kalliath and Beck, 2001). Previous studies show that when supervisors extend the organizational support they receive to their subordinates, employees not only feel supported, they have higher job performance (Shanock and Eisenberger, 2006). Another method of increasing quality of life would be to create an environment in which coworkers feel comfortable speaking to each other about cases which disturbed them. Finally, programs to teach EMS personnel how to increase their personal psychological resilience should be implemented to reduce burnout and STS among EMS personnel. These are programs which would train EMS personnel to develop their ability to self-soothe through activities such as practicing keeping a long-term perspective and viewing the stressful events in a broader context (American Psychological Association, n.d.). Not only is this beneficial to the individual, there is also some evidence that resilience is a mitigating factor in intent to turnover (Hudgins, 2016).
The job of an EMT is probably always going to be stressful, chaotic, and full of exposure to traumatic events. This study shows however that EMS agencies have the ability to reduce the development of maladaptive coping mechanisms in their employees and reducing turnover. Further research should be performed to explore all manners in which management can assist EMTs in performing their jobs.
There are several limitations to this study. The first is the relatively small sample size. Along similar lines, higher response rates would be ideal. Aside from difficulty obtaining statistical significance with smaller sample sizes, low response rates can also potentially raise questions about potential biases related to the representativeness of the respondents. The small number of volunteers and part-time EMS personnel make generalizability of these results tenuous. There are also several potential problems with self-reported surveys. There are sometimes problems with accuracy of the responses. Given the anonymous nature of this study and lack of particularly controversial topics, it is assumed that there is not a problem with inaccurate responses. Because all of the participants were based in Florida, this study may not be generalizable to other locations. Furthermore, by utilizing a cross-sectional study design, this study was also inherently limited to reporting a “snapshot” of the situation and unable to comment on trends within the EMS population. It is impossible to determine causality in this study.
|EMS (n=351) (% of sample)|
|Do you frequently perform tasks in another public safety field?|
|American Indian or|
|Native Hawaiian or|
|Other Pacific Islander||0.6|
|In a relationship||11.7|
|Public safety employment status|
|Highest educational level attained|
|Associate’s degree or|
|Received stress training|
|Do not know||5.1|
Two-tailed Pearson correlation of survey instruments and Cronbach’s α
|SPOS score||PCS score||BRS score||CS raw score||Burnout raw score||STS raw score||Cronbach’s α|
|CS raw score||0.541**||0.435**||0.342**||1||0.912|
|Burnout raw score||−0.553**||−0.391**||−0.502**||−0.704**||1||0.834|
|STS raw score||−0.330**||−0.252**||−0.575**||−0.271**||0.635**||1||0.856|
Notes: SPOS, Survey of Perceived Organizational Support; PCS, Perceived Coworker Support; BRS, Brief Resilience Survey; CS, compassion satisfaction; STS, secondary traumatic stress. **Correlation is significant at the 0.01 level (two-tailed)
Professional quality of life and moderating factors in Florida EMS personnel
|Compassion satisfaction||Burnout||Secondary traumatic stress|
|AD or technical training||1.203||1.891||1.686||1.765||1.089||2.043|
|Stress management training|
|Do not know training||0.950||1.796||1.172||1.676||0.257||1.940|
|Work in other fields||0.345||1.228||−0.366||1.146||1.740||1.326|
|Years of service||0.073||0.060||−0.021||0.056||0.043||0.065|
|Survey of Perceived Organizational Support Score||0.159***||0.032||−0.238***||0.030||−0.177***||0.035|
|Perceived Coworker Support Score||0.271***||0.054||−0.099||0.050||−0.024||0.058|
|Brief Resilience Survey Score||0.289***||0.080||−0.438***||0.074||−0.718***||0.086|
|Speak to Coworkers||−2.738**||0.937||4.242***||0.875||0.495||1.012|
|Offer mental health||−2.826||1.647||1.052||1.537||0.082||1.779|
Notes:UB, unstandardized beta. *p<=0.05; **p<=0.01; ***p<=0.001
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The authors would like to thank the Volunteer Law Enforcement Officer Alliance and The Florida Association of EMS Medical Directors for supporting this research.
About the authors
Dr Anastasia Miller worked in the field as an EMT/Firefighter, after which she attended the University of New Mexico for a BA Degree in Economics, Indiana University – Purdue University Indianapolis, USA for an MA Degree in Economics as well as an MS Degree in Health Informatics and the University of Central Florida for a PhD Degree in Public Affairs with a focus in Health Services Management and Research. She is currently working as an Assistant Professor at the University of Texas Health Science Center at Tyler and hopes to continue researching public safety personnel and the impact they have on population health in rural Texas.
Dr Lynn Unruh has a BSN as well as a BA Degree in Economics from the University of Illinois as well as MA and PhD Degrees in Economics from the University of Notre Dame. She is a Professor of Health Services Administration who has been with the Department of Health Management and Informatics at the University of Central Florida for the past 15 years. Prior to working at UCF, she served as an Adjunct Professor at Indiana University Northwest, and she has more than 25 years of experience in the healthcare field.
Dr Xinliang Liu is an Assistant Professor with the Department of Health Management and Informatics at the University of Central Florida. He conducts quantitative research on health services organizations and quality of care. He is especially interested in the quality of outpatient surgical procedures. Liu holds a Bachelor of Medicine Degree in Medicine and a Master’s Degree in Health Economics and Policy Research. He received his Doctorate in Health Services Organization and Research from Virginia Commonwealth University, Virginia, USA.
Dr Tracy Wharton is a licensed Clinical Social Worker, a Researcher, Program Evaluator, and college-level Mentor and an Instructor. She has a BA Degree in Psychology, Family and Community Systems and an MEd in Counseling Psychology, Marriage and Family Therapy from Cambridge College, an MSc Degree in Social Welfare from Oxford University, an MSW Degree from the University of Michigan, and a PhD Degree in Social Work from the University of Alabama. Her research interests include Military and military-related contractor families, including the impact of PTSD.
Dr Ning Zhang obtained an MD and an MPH Degrees from Shandong University as well as his Doctoral Degree from Virginia Commonwealth University. He is a Professor in the Department of Interprofessional Health Sciences and Health Administration at Seton Hall University. His research focuses on health policy, pharmaceutical outcome research, nurse staffing, clinical outcomes, quality of care, long-term care, disease management, emergency medical services, clinical trial, health informatics and big data analytics. He is a Fellow of the Gerontological Society of America, an Associate Editor of the International Journal of Healthcare Technology and Management and an NIH and CDC grant panel Reviewer.