The importance of helping professions has been recognised world-wide for its valuable contribution in promoting the physical and emotional welfare of the population. During crisis situations, a variety of professions are called upon to be first responders at a scene. The term first responders (FR) refers to professionals such as rescue workers, firefighters, emergency medical technicians (EMTs), police and paramedics (Benedek et al., 2007). Unlike other health professionals, first responders are likely to be first on scene following traumatic events such as car crashes, violent attacks and natural disasters etc. Due to the nature of this role, paramedics and other first-responder professions are likely to experience significant job-related stressors and traumatic exposures which may increase risk for mental health morbidities. Within the first responder professions, paramedics have been found to display higher rates of early retirement on the grounds of mental and physical health compared to other health care staff (Rodgers, 1998). Paramedics are also likely to have a significantly shorter career tenure compared to other health staff, averaging at 2 -4 years (reference).Retirement and tenure data suggest that paramedics are especially susceptible to mental health concerns and shorter career lifespans, highlighting an increased need for support, awareness and interventions within this profession. A range of studies have also found that paramedics are at increased risk for mental health concerns due to high pressure job scenarios, witnessing critical incidents and difficulties with circadian rhythms due to shift work. This has been hypothesized to increase the risk of developing a trauma related disorders (Post traumatic Stress Disorder), mood disorders (Anxiety and Depression), substance use disorders and disrupted circadian cycles. The relevant studies and articles pertaining to each of the aforementioned symptoms will be described below.
Post Traumatic Stress Disorder
Due to frequent and recurrent vicarious trauma exposure, a range of studies have highlighted the increased risk that paramedics and other FR’s have in witnessing traumatic events and becoming personally affected by these events (reference). Of particular concern in these professions, is the development of trauma symptoms, as in post-traumatic stress disorder (PTSD)
The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) defines PTSD based on exposure to trauma and symptoms related to the trauma such as intrusive symptoms, avoidance, negative alternations in cognition and mood, and heightened arousal and reactivity, with symptoms persisting for longer than a month.
Given the criteria definition and the nature of paramedic roles, studies have unsurprisingly found that emergency personnel have a higher occupational risk of developing PTSD due to ongoing exposure to life-threatening situations, death and crisis (reference). A wide range of research has been conducted on the prevalence rate of PTSD across a number of countries, with PTSD prevalence ranging from 4-30% in paramedic populations across the globe.
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Lowest PTSD prevalence rates were found by Michael and Streb (2016) which investigated the prevalence of PTSD symptoms and threat type in a sample of 1363 paramedics in Switzerland. Results found that 4.34% met the criteria for clinical PTSD diagnosis, whilst 9.58% met the criteria for a partial diagnosis, furthermore 23-29 % of participants reported suffering from intrusion, avoidance or heightened arousal symptoms. Similar prevalence rates have been found by Berger et al. (2007) which found that 5.6% of ambulance workers in Brazil met the criteria for a full PTSD diagnosis, whilst a higher 20% met the criteria for a partial diagnosis. Higher prevalence findings in partial diagnosis may reflect a lack on consensus on what constitutes a partial diagnosis, as this guideline is not specifically discussed in the DSM 5 and is based on subjective researcher opinion. It is also important to note that Switzerland has relatively low PTSD prevalence rate in the general population (1.9%), therefore rates found in paramedic populations indicates a significant heightened rate. Contrastingly, PTSD prevalence in Brazil is relatively unknown, however rates are assumed to be higher due to political conflict, corruption and violence. (reference) found that 90% of Brazilian participants interviewed experienced a life-time traumatic event, however symptom descriptions indicated a higher co-morbidity with anxiety disorders rather that PTSD, even in participants who has experienced 3 or more traumatic events. Findings suggest that cultural differences may influence manifestation and expression of trauma symptoms.
Threat type in relation to PTSD symptoms was also examined by Michael and Streb (2016) which found that 33% of paramedics reported experiencing indirect threats, whilst 66% reported experiencing direct threats. Participants which experienced direct threats were also more likely to exhibit higher levels of cognitive distortions and PTSD symptoms. This finding is also consistent with Piotrkowski and Brannen (2002) who found that direct threats significantly increased cognitive, intrusion and avoidance symptoms of PTSD.
Higher rates of PTSD prevalence have been found by Bennett et.al (2004) who examined a sample of 617 UK paramedics and found that 22% of participants met the criteria for PTSD, the study also found that 10% and 22% met the criteria for clinical depression and anxiety respectively. Given that the general population rates for PTSD in the UK is 4-5%, findings indicate a significant increased risk for paramedics. High rates of PTSD symptoms were also found in 110 Scottish ambulance workers (Alexander & Klein, 2001), with 82% experiencing one or more work traumas. Within this sample 30% reported high severity of PTSD symptoms, whilst 60% reported medium to low severity of symptoms. Variables influencing severity levels included trauma exposure, depressive symptoms, lower social support and resilience factors. However, PTSD symptoms in this study where not measured against the DSM criteria and severity scores where based on the ‘Impact of Event Scale’ questionnaire and are not indicative of clinical diagnosis.
Several studies have also investigated PTSD symptomology in paramedics students. In particular, Grevin (1996) examined the prevalence of PTSD between paramedics and paramedic students and found minimal differences with 20 and 22% prevalence rates respectively. This study also examined cognitions between groups compared to a normative sample. Interestingly, both groups displayed significantly higher levels of denial and repression and lower levels of reaction formation and empathy compared to normative samples. Paramedics and students with higher denial and lower empathy levels showed negative correlation with PTSD symptoms suggesting that such traits may be protective factors in this profession. Supporting research by Fjeldheim et al. (2014) in South Africa found similar rates of PTSD at 16% for first year students. Results from both studies suggest that PTSD symptoms may be independent of time in service and that other factors may need to be considered. Fjedeim (year) also suggests that personal experience and life events may influence paramedic career choice, as 38.4% of paramedics reported exposure to childhood trauma, thereby partially accounting for possible homogenous cognitions and PTSD symptoms within groups.
Whilst PTSD prevalence rates were found to be similar in paramedics and students, other studies have found significant difference between paramedic experience and other mental health outcomes. Cydulkaet.al (1989) found that high stress in paramedics correlated positively with age and time in service. Whereas other studies found that less experience is associated with suicidal risk (Beaton et al., 1999; Corneil et al., 1999; Wagner et al., 1998). Explanations for discrepancy in findings suggest that mental health outcomes in students are influenced by feeling ill-prepared, helpless and overwhelmed (reference), whilst more experienced paramedics are more susceptible to prologued trauma exposure and increased performance pressure despite some desensitisation effects found(reference).
Aside from directly measuring PTSD symptoms, several studies have examined other factors which correlate to trauma and mood disorders within the first responder population. Supporting studies on cognitive processes found that paramedics which endorsed wishful thinking, dissociation, negative interpretation of events and maladaptive response styles where more likely to develop PTSD or a mood disorder (Clohessy & Ehlers,1999). Research by Van der Ploeg and Kleber (2003) also found that fatigue and job burn-out significantly increased the risk of sick leave and work disability. Predictors of burnout where found to be lack of social support, less recovery time, increased exposure and poor organisation communication. Similarly, a Dutch study found that lack of supervisor and family support greatly increased the likelihood of burnout and psychopathology. Given that stress and burn-out is likely to be similar for individuals with high pressure jobs, one particular study examined differences between 26 high demands occupations and found that paramedics ranked highest for negative health impacts, fourth in psychological distress and second highest for low job satisfaction. Similarly, Grigsby and McKnew (1988) measured burnout in a sample of 213 paramedics using the Staff Burnout Scale for Health Professionals and found that paramedics in this study showed the highest burnout compared to all other health professions on the same measure. This research highlights that paramedics are especially susceptive to adverse health outcomes, even compared with other high-demand professions, highlighting the need for future intervention studies to combat the effects of burn-out.
In an attempt to understand protective factors in paramedcis, some studies have further focused on resilience in this population and resilience factors. High resilience was found to be correlated to positive self image, job satisfaction, increased support, realistic expectations , positive attitudes , coping styles, good physical health and mental health. Studies by Alexander and Klein (2001) also suggest the benefits of a ‘hardy’ personality which is logical, focused and practical. Supporting studies by Bartone et.al (2008) found that a ‘hardy’ personality was associated with less negative trauma experiences in soldiers. One possible explanation proposed for this is that the ‘natrual selection’ process which suggests that only those paramedics with protective personality and coping traits can withstand the demands of the profession, develop faster resilience and psychological recovery(Gillespie, Chadboyer, Willis, & Grimbeek, 2007). Whilst this explanation may be sound in theory, there is currently a lack of empiral data to validate these claims.
The concept of resilience is difficult to ascertain from literature findings due to lack of conceptual clarity, however for the pruposes of paramedic study most researches have focused on measuring paramedics adaptation to stress via positive emotional and behavioural coping strategies. Given the short tenure of paramedcis, studies have sought to examine resilience rate in paramedic students, compared to qualified paramedcis. Results found that students where significantly less resilient then experienced paramedcis. These findings suggest that resilience increases with experience. Interestingly, within the experienced paramedic groups, resilience levels where found to decrease after 5 years of service, which is unsprinsg considering the short tenure rate of paramedcis. Explanations of this effect include the concept of “stress inoculation” and a “plateu” of resilience followed repeated trauma exposure. This theory suggests that resilience can be developed following trauma experience, however that continuous trauma exposure can accumulate past adaptive resilience responses leading to decline.
Depression, Substance Use and Sleep
Whilst PTSD rates have been widely explored in the paramedic population, fewer studies have focused on depression symptoms. Given the high co-morbidity of these disorders, paramedics have also been found to be at increased risk for the development of major depressive disorder due to similar vulnerabilities and predictor variables (reference) s. Whilst suicidality and depression have widely been explored in police officers and firefighters, scare research can be found in this area for paramedics.
Results from previous studies indicate a 3-28% prevalence rate of severe depression symptoms in paramedics, with most studies endorsing a 6% prevalence rate (Fjeldheim et al., 2014; Regehr et al., 2000). Depression was also found to be a mediating factor for PTSD symptoms, with 16 years of service being positively correlated to symptom severity (Bentley, Crawford, Wilkins, Fernandez, & Studnek, 2013). Supporting studies by Sterud et.al (2008) found a prevalence rate of 28% in individuals reporting feeling life is not worth living, 10.4% for serious suicidal ideation and 3.1% for a past suicide attempt. Interestingly, when investigating self-reported causes for mood symptoms only 1.8% of paramedics attributed this solely to their work role, whilst 11% indicated that work was a factor. It is important to note that the wide prevalence rate of depressive symptoms between studies is based on depressive measures used, for example the 28% prevalence rate is based on all paramedics endorsing a particular question item. Few studies investigating depression have used clinical measures which provide clinical diagnosis.
Another area requiring further research is substance abuse in the paramedic population. Among FRs, data are limited to the fire service with only one study assessing alcohol use in South African paramedic students. Results from this study found a high 23% prevalence rate meeting the criteria for alcohol abuse. Regeher et.al (year) also found that substance use was likely to increase by up to 9x following a traumatic event, highlighting that substance use may be employed as a maladaptive coping strategy for some professionals. Given these findings, future research in this area may be beneficial to understanding the coping mechanisms and development of substance use disorders amongst this population.
Another important area for consideration is the impact of shift cycles, sleep deprivation and fatigue on mental health outcomes and job performance. Various studies have examined the importance of mental alertness in the paramedic profession due to high speed driving, crisis responding and drug administration. Furthermore, alertness, vigilance, concentration, judgement, mood and performance are signiﬁcantly affected by fatigue, with memory impairment, problem solving and decision-making leading to decreases in work productivity and performance (reference) .Average shifts for paramedics range between 8-24 hours which significantly increase sleep deprivation and associated factors. Sleep deprivation is defined as less than 4 to 6 hours of sleep in a day. The effects of sleep deprivation can lead to fatigue, decreased alertness, and poor concentration. It can also contribute to decreased quality of life, cognitive impairments, and mood disturbances (de Barros, Martins, Saitz, Bastos, & Ronzani, 2013). Unsurprisingly, sleep deprivation is common among FRs due to the hours of operation and nature of the profession. Studies regarding sleep deprivation and fatigue found that 70% of paramedics reported poor sleep outcomes (Courtney, Francis, & Paxton, 2013). This group also reported significant chronic fatigue and depression, with over 12% reporting severe to extreme severe levels of depression. A study regarding the health and stress of Victorian ambulance services was conducted in 2002, results showed an increase in reported fatigue by 9% in the last 9 years. Fatigue and sleeping difﬁculties were among the most commonly reported symptoms frequently experienced (75%), whilst 66% reported that shift work disrupted their personal lives.
In order to address difficulties reported with sleep deprivation, a Japanese study introduced a trial which guaranteed naps for paramedics at designated times. Whilst the study found that this improved fatigure complatings , the logistics of assuring nap times were difficult to uphold due to the nature of the profession (reference). Given the improvement in reported fatigue, further research in this area may be beneficial in meeting paramedics sleep requirements whilst balancing role logistics.
The impact of shift work and long hours was also found to effect the work-life balance of paramedics and other FR professionals. Roth and Moore (year) families initially had difficulty adjusting to shift work hours, and that schedules disrupted home routines, holidays and contributed to family changes. Furthermore, Mood diaries in one study by (reference) showed that paramedics felt more unhappiness, stress and sadness and fewer feelings of pleasantness at home than at work. One hypothesis as to the cause of this , is that shift roles may cause conflict at home and expect family demands of workers when they have days off. Despite these ﬁndings, research by (reference) emphasis that families become increasing resilient over-time and adapt to changes. One particular study found that the majority of experienced paramedics (79.1%) indicated that their spouses were often or very supportive. The majority (56.8%) also felt supported by friends and colleagues, however, perceptions of employer support were contrastingly low. Only 10.8% reported that their employers where very supportive whilst 35.1% reported feeling rarely or never supported. Of particular concern was the number of paramedics endorsing that the union was rarely or never supportive (80%). Results from this study, highlight that organisational deficits may also contribute to psychopathology and stress symptoms within this industry.
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Further research conducted in this area found that managerial support was a strong predictor of stress and burnout factors. Thompson (1993) found that paramedcis rated poor managerial relationships and feeling devalued as the most stressful aspects of their profession. Supporting studies also found that organisational stress, particuarily from supervisors was a strong mediating factor for stress. (Burke, 1993; Buunk & Peeters, 1994; Gibbs, Drummond, & Lachenmeyer, 1993; Leffler & Dembert, 1998; Weiss, Marmar, Metzler, & Ronfeldt, 1995). Whilst difficult relationships with co-workers was rarely reported, difficulty with co-workers was the strongest predictor of burnout (reference). Conversely, positive supervisors and work support significantly reduced work-stress, depression and anxiety. Furthermore, perceived support from management following crisis situations was associated with lower stress, disability and workplace termination. (Regehr & Bober, 2005; Regehr, Goldberg, Glancy, & Knott, 2002; Thompson, 1993). Such findings led Gist and Woodall (1995) to conclude that trauma exposure has minimal impact on paramedics compared to organizational frustration and deficits. Other authors suggest that the combination of organisational factors and traumatic experiences increases stress and work demands, thus both contributing to negative mental health outcomes (Coman & Evans, 1991).
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