Evaluation of Stress Experienced by Emergency Telecommunications Personnel Employed in a Large Metropolitan Police Department

Abstract

Emergency telecommunications personnel (ETCP) form the hub of police agencies and persistently deal with distressing situations on a daily basis, making them highly susceptible to psychological and physiological ailments. To date, few studies have examined the necessity or feasibility of implementing a resilience training intervention for ETCP. In this study, the authors assessed baseline psychological data from the ETCP of a large police department to determine the differences in baseline measures for ETCP and police officers. Participants included ETCP ages 29 to 64 years (n = 19). Results showed that ETCP self-reported greater levels of psychological stress compared with police officers (p < .05) for the majority of measures; ETCP experience excessive levels of stress and greater prevalence of chronic disease. Consideration should be given to piloting resilience interventions within this group to manage stress; improve health, performance, and decision making; and decrease the prevalence of chronic disease.

Keywords

telecommunications emergency response psychological stress stress dispatchers

The literature on occupational stress among law enforcement personnel has increased substantially over the past decade. Study results have revealed factors (e.g., critical incidents, shift work, and organizational stressors) ubiquitous to law enforcement occupations, which exacerbate officer stress (Puttonen, Harma, & Hublin, 2010; Ramey, Downing, Franke, Perkhounkova, & Alasagheirin, 2012). These occupational stressors are associated with a higher prevalence of cardiovascular disease (CVD) and its risk factors (i.e., hypercholesterolemia, hypertension, tobacco use, obesity, physical inactivity, and hyperinsulinemia), which are more prevalent among police officers than the general population (Hartley, Burchfiel, Fekedulegn, Andrew, & Violanti, 2011; Ramey, Downing, & Franke, 2009; Ramey, Perkhounkova, Downing & Culp, 2011; Wright et al., 2011; Zimmerman, 2012).

Emergency telecommunications personnel (ETCP), a select sub-group of sworn and civilian emergency service workers, experience a majority of the same day-to-day stressors as police, yet little attention has been given to this sub-group. It may be assumed that because ETCP are not in the field, their exposure to stressful events is removed, and they are, therefore, less likely to experience the negative consequences of stress. However, ETCP are the first contact in the Emergency Medical System and thus a crucial part of the response team. These employees require a skill set that equips them to be prepared to deal with circumstances that evoke a stress response, with limited breaks between calls.

Emergency telecommunications personnel orchestrate many departmental activities and play a significant role in ensuring the safety of civilian callers and officers on the street. However, being the first line of communication when disaster strikes, ETCP must be emotionally prepared for traumatic events such as unexpected injury or death of a child, suicide, domestic violence, officer shooting, or homicide (Pierce & Lilly, 2012), and the repercussions of these incidents. In addition, ETCP are responsible for processing complex information while making rapid but effective decisions, working under pressure, multi-tasking, and managing emotions (Burke, 2005; Gurevich, Halpern, Brazeau, Defina, & Schwartz, 2006).

Due to the parallel stressors police officers and ETCP share, ETCP develop many of the adverse physical and psychological consequences of stress (i.e., depression, post-traumatic stress disorder [PTSD; Lilly & Pierce, 2012; Pierce & Lilly, 2012; Regehr, LeBlanc, Barath, Balch, & Birze, 2013], acute distress disorder [Trachik et al., 2015], job dissatisfaction, and burnout [Anshel, Umscheid, & Brinthaupt, 2013; Burke, 2005; McCarty & Skogan, 2013]). Regehr and colleagues (2013) found the prevalence of PTSD among ETCP to be 31%, which is much greater than the prevalence of PTSD among police officers (8.3%; Bowler et al., 2010) and the general population (3.5%; Kessler, Chiu, Demler, Merikangas, & Walters, 2005). The development of PTSD symptoms has been shown to be related to peritraumatic distress, which occurs during or immediately after a traumatic experience (Thomas, Saumier, & Brunet, 2012). In a survey of 131 emergency dispatchers, peritraumatic distress was much higher among ETCP than among police officers or the general population; the severity of PTSD was strongly associated with peritraumatic distress (Pierce & Lilly, 2012).

Compared with the general population, ETCP have demonstrated elevated levels of psychological stress and occupational burnout (Ksionzky & Mehrabian, 1986; Trachik et al., 2015). Trachik and colleagues (2015), who surveyed 205 emergency dispatchers, found that 17% of this population was suffering from acute stress disorder and that the level of secondary traumatic stress and occupational burnout was greater than the prevalence in the general population. This high level of occupational burnout is strongly related to job dissatisfaction, stress, and strain (Burke, 1995). Emergency telecommunications personnel also report work–life imbalance, lack of control over work environment, sleep deprivation, lack of social support, and conflict-prone relationships with coworkers and supervisors (Behr, 2000; Kirmeyer, 1988; McCammon, Durham, Allison, & Williamson, 1988; McCarty & Skogan, 2013; Shepherd & Hodgkinson, 1990). Some of these psychological stressors differ by gender; ETCP units are frequently comprised of predominately female employees (Lilly & Pierce, 2012). Similarly, female police officers have been shown to have higher stress levels than their male counterparts (p < .01) with a higher prevalence of hypercholesterolemia (46.2% vs. 29.3%, p ≤ .01) and a trend toward higher rates of diabetes (9.2% vs. 4.5%, p = .084; Yoo & Franke, 2011).

It is clear that the development of better coping and stress management for this population is needed (A. Williams, personal communication, September 25, 2015). For instance, ETCP who are highly stressed may struggle to make decisions and effectively perform their work duties (Gurevich et al., 2006). As a result of unavoidable and frequent ETCP exposure to stressors, interventions should improve ETCP resilience (i.e., the capacity to prepare for, recover from, and adapt in the face of stress, adversity, trauma, or challenge; McCraty & Atkinson, 2012). Due to similar exposures among dispatchers and police officers, current interventions developed for police officers may be suitable for ETCP as well. However, currently, only a few studies have examined interventions for dispatchers (Anshel et al., 2013; Weltman, Lamon, Freedy, & Chartrand, 2014).

Anshel et al. (2013) examined the effectiveness of a coping and wellness program in a small sample (n = 9) of dispatchers and found the 10-week intervention increased the use of avoidance coping strategies and significantly improved perceived stress and perceived physical energy. Weltman and colleagues (2014) implemented a resilience intervention (i.e., stress and self-regulation skill training using the Stress Resilience Training System [SRTS]; iPAD App) for both police officers (n = 12) and dispatchers (n = 2). The study found improvements in stress levels of 40% as well as improvements in both on-the-job performance and personal and familial situations. Although the intervention was effective, the dispatcher sample was small, so results had limited generalizability. Therefore, the purpose of the current study was to (a) collect baseline data to support implementation of an intervention to build resilience in ETCP and (b) compare ETCP reported stress with police officers’ reported stress within the same police department. Given the duties and types of stress experienced by the ETCP, interventions should address stress management and improve performance, decision-making, and health.

Method

This study was conducted in a “top 20” U.S. police department in terms of size. The research team had a strong relationship with the department, and the venue provided a large sample of potential participants who work within a large metropolitan police department.

Emergency telecommunications personnel are predominately female and civilians in this police department. Only 10 employees are male. The ETCP also staff the Differential Police Response Unit (DPRU) when staffing allows. For simplicity, the authors refer to telecommunicators, dispatchers, and DPRU officers collectively as ETCP (n = 106).

The area served by the department is composed of 96.8 square miles. The population of the city is just below 600,000 residents. The department consists of seven districts with a total of 1,800 sworn officers, detectives, and supervisors. Most recent data, from January to December 2015 (Avaya CMS Reporting System), indicated that the telecommunications department received more than 850,000 calls, an increase of 30,000 calls from the previous year (January to December 2014).

Study Design and Data Collection Procedures

This descriptive, cross-sectional study began with an announcement inviting employees to participate at the beginning of all shifts on two separate occasions. Information about the study was also posted electronically for potential participants to review. Packets containing five surveys and a cover letter were available in the Sargeant’s office; all ETCP begin their shifts in this office. All staff were handed a sealed survey packet as they arrived at work. According to the cover letter enclosed in the sealed envelope, ETCP were to return the surveys in the envelope provided even if they opted not to complete the survey packets. Surveys were distributed in November of 2015, and participants were given 1 week to return the survey packets. Employees deposited their sealed envelopes in a conveniently located box within the ETCP unit; hence, neither the researchers nor ETCP was aware of who completed the survey packets. The University of Iowa Institutional Review Board approved this study; returning a completed survey implied consent.

Measures

Participants completed one health and lifestyle questionnaire and five comprehensive self-reported paper-and-pencil measures of stress once. These instruments have been used in previous research studies and determined to successfully measure distinct, yet complementary, behavioral and emotional dimensions of stress. Together, they provide a broad range of psychological and behavioral outcome indicators necessary to initially assess target populations prior to designing interventions to modify reactions to stress. Each of these survey instruments has been determined to be reliable and valid (Cohen et al.,1983; Appels & Schouten,1991; Horowitz, et al., 1979; Barrios-Choplin & Atkinson, 2000; Johnson, et al., 2011). They are described in Table 1, along with reliability information.

Table 1.

Psychological Measures of Stress

Type of stress	Variables	Instrument	Reliability
Personal	Global measure of stress	Perceived Stress Scale: 14-item survey answers Likert-type responses (Cohen, Kamarck, & Mermelstein, 1983)	Cronbach’s alpha = .75 (Cohen et al., 1983)
	Vital exhaustion	Maastricht Questionnaire 9-item version of Form B: including feelings of fatigue, irritability, and demoralization answers Likert-type responses	Cronbach’s alpha = .83 (Appels & Schouten, 1991)
Acute	Critical incident stress and post-traumatic stress syndrome	Impact Events Scale: 15-item measure of response to critical incident stress after a traumatic event (Horowitz, Wilner, & Alvarez, 1979)	Cronbach’s alpha = .87 for the total scale (Horowitz et al., 1979)
Organizational	Personal and organizational constructs	Personal and Organizational Quality Assessment-R: 53-item measures physical stress, resilience, organizational climate, and work performance (Barrios-Choplin & Atkinson, 2000)	Cronbach’s alpha for subscales = .76-.92 (Barrios-Choplin & Atkinson, 2000)
Resilience	Cognitive flexibility, meaning making, active coping, spirituality	Response to Stressful Experiences Scale: 22-item survey answers Likert-type responses (Johnson et al., 2011)	Cronbach’s alpha = .91-.93 (Johnson et al., 2011)

The Perceived Stress Scale is used to assess how participants cognitively appraise life events (Cohen, Kamarck, & Mermelstein, 1983). The questions ask participants to rate how predictable, controllable, and overwhelming their lives have felt in the past month. Vital exhaustion is a measure of self-reported stress symptoms related to sleep quality and irritability in relation to work and fatigue (Appels & Schouten, 1991).

The Impact Events Scale is designed to measure current feelings of stress caused by any life experience. The scale is broken into two subscales, intrusion and avoidance, and is designed to measure PTSD (Horowitz, Wilner, & Alvarez, 1979).

The Personal and Organizational Quality Assessment queries participants about how adequately each statement relates to their lives. The statements are split into four groups. The first group consists of single words describing various emotional and physical states. The second group indicates general health and stress levels. The third group reflects how individuals may feel about themselves, and the fourth group reflects job satisfaction. The scale reveals the reciprocal interaction between the workplace and the employees (Barrios-Choplin & Atkinson, 2000).

The Response to Stressful Events Scale measures resilience; items are grouped into six factors including cognitive flexibility, meaning making, active coping, spirituality, self-efficacy, and restoration. Each factor represents a characteristic that promotes healthy responses to stress (Johnson et al., 2011). These self-reported stress measures were designed to assess both personal and occupational stressors.

Statistical Analysis

The researchers used SAS 9.4 to analyze study data. Descriptive statistics were calculated for all study variables, including demographic data. An independent samples student’s t test was used to compare mean scores on psychological measures of stress for the ETCP group (n = 19; combining telecommunicators, dispatchers, and one DPRU officer) to mean scores for a sample of police officers working in the same department (n = 38) but collected during two earlier pilot studies prior to implementation of a resilience intervention. An alpha level of p < .05 was chosen for all statistical tests.

Results

Surveys were completed and returned by 19 of 106 ETCP (18%). Demographic, lifestyle, and health characteristics for the study populations are presented in Table 2. In this study of ETCP, 61% of the participants were telecommunicators, 33% were dispatchers, and 6% were DPRU officers. The majority of ETCP participants were female (80%); the comparison group of police officers was primarily male (76%). African Americans were also more frequently represented in the ETCP group (41%) than the police officer group (18%). Age and years in the department were similar across both groups. Police officers self-reported a higher prevalence of physical activity (i.e., participation in physical activities or exercise such as running, calisthenics, golf, gardening, or walking, during the past month) compared with the ETCP group (87% vs. 61%, respectively). Evaluation of metabolic health showed that the ETCP group reported a higher prevalence of hypertension, CVD, and diabetes than the comparison group of police officers.

Table 2.

Demographic, Lifestyle, and Health Characteristics

	ETCP		Police officers
Variable	n	M ± SD (range)	n	M ± SD (range)
Years in the department	17	12.7 ± 6.8 (1-25)	38	14.7 ± 7.0 (1-23)
Age (years)	18	46.4 ± 11.5 (29-64)	38	41.1 ± 7.6 (22-54)
	n	%	n	%
Gender
Male	3	20	29	76
Female	12	80	9	24
Race
African American	7	41	7	18
White	9	53	27	71
Other	1	6	4	11
Group
Telecommunicator	11	61
Dispatcher	6	33
DPRU officer	1	6
Engaged in physical activity
Yes	11	61	33	87
No	6	33	5	13
Don’t know	1	6	0	0
Hypertension
Yes	12	67	15	42
No	6	33	21	58
Hypercholesterolemia
Yes	7	39	18	47
No	11	61	20	53
CVD
Yes	1	6	1	3
No	17	94	37	97
Diabetes
Yes	4	24	2	5
No	13	76	35	95

Note. Because of missing data, n for each variable may differ. Percentages may not sum to 100% due to rounding. Demographic information was missing for one participant in the ETCP group. CVD = cardiovascular disease.

Psychological Measures

Descriptive statistics for ETCP and police officer psychological measures are presented in Table 3. Mean scores on the Perceived Stress Scale (M = 27.7, SD = 8.0, and M = 20.6, SD = 6.8) and Vital Exhaustion Scale (M = 21.3, SD = 4.6, and M = 16.5, SD = 4.7) were significantly higher (p < .001) for ETCP than for police officers. With regard to the Impact of Events Scale, the Intrusive Subscale mean score for ETCP was more than double the police officers’ mean score (M = 18.7, SD = 8.2, vs. M = 8.2, SD = 8.0, p < .001), and the Avoidance Subscale mean score was also substantially higher for ETCP (M = 17.1, SD = 8.4, vs. M = 10.8, SD = 9.7, p = .02) than police officers. Although only marginally significant, the ETCP mean score on the Response to Stressful Experiences Scale was greater than police officers’ mean score (M = 69.7, SD = 10.4, vs. M = 62.9, SD = 13.1, p = .05).

Table 3.

Descriptive Statistics for Psychological Measures of Stress.

	ETCP (n = 19)		Police officers (n = 38)
	M ± SD	Range	M ± SD	Range	p ^a
Perceived Stress Scale (0-56)	27.7 ± 8.0	12-43	20.6 ± 6.8	5-33	<.001
Vital exhaustion (9-27)	21.3 ± 4.6	11-27	16.5 ± 4.7	9-25	<.001
Impact of Events Scale
Intrusive Subscale (0-35)	18.7 ± 8.2	1-33	8.2 ± 8.0	0-29	<.001
Avoidance Subscale (0-40)	17.1 ± 8.4	3-32	10.8 ± 9.7	0-34	.02
Total stress score (0-75)	35.8 ± 13.8	11-62	19.1 ± 15.8	0-47	<.001
Response to Stressful Experiences Scale (0-88)	69.7 ± 10.4	38-85	62.9 ± 13.1	42-86	.05
Personal and Organizational Quality Assessment
Emotional Vitality Scale (1-7)	3.9 ± 1.2	2.1-5.9	4.5 ± 1.0	2.5-6.3	.06
Emotional buoyancy (1-7)	3.9 ± 1.4	1.3-6.1	4.6 ± 1.1	1.9-6.5	.04
Emotional contentment (1-7)	3.9 ± 1.3	2.0-6.0	4.3 ± 1.1	1.7-6.0	.20
Organizational Stress Scale (1-7)	4.9 ± 1.1	2.8-6.9	3.8 ± 1.2	1.4-6.2	.001
Pressures of life (1-7)	4.4 ± 1.2	2.2-7.0	3.7 ± 1.3	1.0-6.4	.05
Relational tension (1-7)	5.7 ± 1.2	2.7-7.0	4.3 ± 1.6	1.3-7.0	<.001
Intention to quit (1-7)	5.5 ± 1.7	1.0-7.0	2.5 ± 1.9	1.0-7.0	<.001
How stressed have you been (1-15)	11.1 ± 3.5	4.0-15.0	7.1 ± 3.3	1.0-14.0	<.001
Emotional Stress Scale (1-7)	3.3 ± 1.0	1.7-5.6	2.4 ± 0.8	1.3-4.4	<.001
Anxiety and depression (1-7)	3.4 ± 1.2	1.4-6.0	2.2 ± 0.9	1.0-4.9	<.001
Anger and resentment (1-7)	3.2 ± 0.9	1.9-5.1	2.5 ± 0.8	1.3-4.4	.01
Physical Stress Scale (1-6.8)	3.7 ± 1.2	1.7-5.7	2.8 ± 1.2	1.1-5.5	.01
Fatigue (1-6.8)	4.4 ± 1.7	1.0-7.0	3.4 ± 1.6	1.0-6.5	.02
Health symptoms (1-6.8)	3.2 ± 1.1	1.8-5.2	2.5 ± 1.0	1.2-5.3	.02

Note. Lower score is better for Perceived Stress Scale, Vital Exhaustion, and Impact of Events Scale. Higher score is better for Response to Stressful Experiences Scale. On the Personal and Organizational Quality Assessment, higher score is better for the Emotional Vitality Scale; lower score is better for the Organizational Stress Scale, the Emotional Stress Scale, and the Physical Stress Scale.

p values for the independent samples two-tailed t test.

Comparison of mean scores on all subscales of the Personal and Organizational Quality Assessment revealed significant disparities between ETCP and police officers on almost all measures of stress and emotional vitality, with ETCP showing more stress and less emotional vitality than police officers (Emotional Vitality Scale: 3.9 for ETCP, SD = 1.2, and 4.5 for police officers, SD = 1.0, p = .06; Organizational Stress Scale: 4.9 for ETCP, SD = 1.1, and 3.8 for police officers, SD = 1.2, p = .001; Emotional Stress Scale: 3.3 for ETCP, SD = 1.0, and 2.4 for police officers, SD = 0.8, p < .001; and Physical Stress Scale: 3.7 for ETCP, SD = 1.2, and 2.8 for police officers, SD = 1.2, p = .01).

Discussion

Emergency telecommunications personnel self-reported greater levels of psychological stress compared with police officers for the majority of measures. The percentage of ETCP who self-reported hypertension (67%) in this study was greater than that reported by police (42%) and more than twice the percentage of reported hypertension in the general population of adults age 20 years or older (32.6%; Mozaffarian et al., 2015). In this sample, rates of self-reported diabetes were almost five times higher for ETCP compared with police (24% vs. 5%) and greatly exceeded rates reported by the general population (9.9%; Mozaffarian et al., 2015). Emergency telecommunications personnel self-reported CVD at twice the rate reported by police (6% vs. 3%; Table 2).

Most of the telecommunications units previously studied were predominately female, Similar to study findings, other researchers found (a) female officers reported more stress than male officers and (b) a trend toward a higher prevalence of diabetes in female officers (9.2 vs. 4.5%, p = .084; Yoo & Franke, 2011). Because the ETCP in this study was 80% female, gender may play a role similar to the role played by female police officers who have been shown to report more stress than their male counterparts (p < .01) with higher prevalence of hypercholesterolemia (46.2% vs. 29.3%, p ≤ .01; Yoo & Franke, 2011). Gender differences may in part explain the higher prevalence of self-reported stress and chronic illness (e.g., hypertension, diabetes, and CVD) found in this study. However, no studies were found that specifically studied ETCP as a comparison group.

Previous study results have supported ETCP’s perceived inadequate support from supervisors and coworkers as well as their perceived job role complexity (Behr, 2000; Kirmeyer, 1988; McCarty & Skogan, 2013; Shepherd & Hodgkinson, 1990). Therefore, it is not surprising that turnover and PTSD rates are higher among these employees and may in part explain why the authors found much higher means for Impact of Events Scale (a measure of PTSD) and the Intrusive Subscale scores. Greater stress in this study group are similar to and supported by previous studies that found the prevalence of PTSD among police communicators to be 31% (Regehr et al., 2013), which is much greater than the prevalence of PTSD among police officers (8.3%; Bowler et al., 2010).

A surprising finding was that the Response to Stressful Experiences Scale, a measure of resilience (though only marginally significant), showed ETCP reported greater resilience than police officers, with a higher score on this scale indicating greater resilience. This finding is interesting because it implies that despite the finding of greater stress by the ETCP group, ETCP may cope better with job stress than police officers. Although other studies have queried stress in telecommunicators, no known studies to date have specifically measured resilience in telecommunicators.

Because greater prevalence of CVD is already well documented in law enforcement officers and, according to Yoo and Franke (2011), female officers have been found to have higher stress (p < .01) and higher hypercholesterolemia (46.2% vs. 29.3%, p ≤ .01) than their male counterparts, researchers must focus on the risk factor prevalence identified in this study, especially the high levels of self-reported stress and chronic illness found within this sub-group of law enforcement staff, and intervene accordingly. Early intervention to empower employees to modify their reactions to stress may not only improve the general health and well-being of these individuals but also reduce the prevalence of chronic illness and job turnover.

Limitations

The survey return rate for this study was lower than expected; therefore, study results may not fully represent the ETCP group. The low return rate may in part be related to the timing of the project. Dissemination of the survey packet coincided with the unanticipated simultaneous distribution of a human resources department survey to the same group, and confusion may have resulted. Due to the small sample size, more sophisticated analytic techniques could not be employed.

In addition to the small sample size, other limitations include the high variability of most measures. Because history of specific chronic disease was self-reported, the prevalence of chronic disease should be interpreted with caution. Stress levels and rates of chronic illness may also vary more in smaller police agencies compared with large metropolitan police departments. Despite these limitations, significant differences were identified between the ETCP and police officer groups.

Implications for Practice

Collection and analysis of baseline health information can provide an estimate of illness prevalence and the relationship between stress and these illnesses. When workers experience chronic occupational stress, chronic illnesses (e.g., hypertension, hypercholesterolemia, and diabetes) may result. All these illnesses can potentially predispose employees to CVD. Therefore, it is important to detect these risk factors early and implement interventions to address occupational and organizational stress and worker stress resilience before costly chronic disease manifests. Using existing, validated instruments to determine levels of stress and illness may not only increase employees’ awareness about their health and stress levels but also may identify appropriate interventions that will reduce costs by preventing chronic disease development.

Conclusion

Results of this small pilot study support that this cohort of ETCP within a large police department experience significantly more stress than police officers in the same department. The findings suggest that this group might benefit from an intervention designed to improve resilience. The types of stress experienced by ETCP are likely compounded by shift work in a predominately female cohort. Larger studies, beyond this small pilot, should be conducted to better understand the stress associated with ETCP within a large metropolitan department as well as other police departments. Ignoring this group’s stress may perpetuate health issues and chronic illnesses (e.g., hypertension and hypercholesterolemia). Consideration should be given to piloting resilience interventions with ETCP to improve their health, performance, and decision making. High turnover rates, job dissatisfaction, and chronic illness, especially CVD, all pose fiscal burdens to an already taxed public service system. Addressing these issues for ETCP may reduce turnover rates and conserve resources spent on health care by improving worker health and decision making.

Applying Research to Practice

The results of this study demonstrate that frontline personnel, specifically ECTP staff, self-report stress levels equal to or greater than those reported by police officers. Implications of this finding include the importance of sharing these findings with the target population with subsequent provision of education about ways to mitigate job-related and general stress. It is important to detect this risk early and implement interventions, such as resilience training, that will empower all law enforcement employees to modify how they manage stress. Querying groups like these personnel and officers is a first step toward tailoring and implementing interventions to improve health, communication, decision-making, and performance, which directly benefit the citizens and communities they serve. More needs to be known about the health and stress levels experienced in all professions, and the work conducted here is applicable beyond the police force.

Footnotes

Acknowledgements

The authors thank the members of the police department and the administration for their participation in the study and their continued support of health promotion research.

Conflict of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by a grant from The University of Iowa College of Nursing, Office for Nursing Research and Scholarship.

Author Biographies

Sandra Ramey is academic faculty from the College of Nursing at the University of Iowa, Iowa City, IA. She holds a secondary appointment in the College of Public Health where she is an affiliate with the Healthier Workforce Center for Excellence.

Yelena Perkhounkova is the statistician manager at the College of Nursing, University of Iowa, Iowa City, IA, where she provides dedicated support for the research efforts of collegiate faculty. She has performed statistical analyses for a variety of experimental and observational studies.

Maria Hein provides research assistance and data management support for faculty research at the College of Nursing, University of Iowa, Iowa City, IA.

Sophia J. Chung is an assistant professor in the Department of Nursing, University of Ulsan in South Korea.

Amanda Anderson is a PhD candidate in the Department of Kinesiology, Iowa State University, Ames, IA.

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