The role of the paramedic has gone through seismic change since its inception in the 1960s and is no longer limited to the management of advanced life support and disaster. Paramedics must now be confident and competent to manage and adapt to a multitude of presentations, especially as the service has become the most accessible form of healthcare in the UK (Eaton et al, 2018). With such diversity in types of demand and an increased dependence on the service, paramedics are now under more pressure than ever before (BBC News, 2019; Unison, 2022).
The current attrition rate of 10.3% annually, an increase of over 5% since 2011, and paramedic diversification into non-traditional working environments (Nuffield Trust, 2022) indicate that it is time to focus on the wellbeing of practitioners. This includes examining the potential for heightened stress and anxiety, which can, in some cases, lead to suicidal ideation and suicidality.
Research has found that occupational and organisational burdens, such as shift work and extensive hours, have a significant detrimental impact upon staff welfare of (Kirby et al, 2016). The camaraderie and stoicism inherent to emergency service professions prevents openness and stalls the improvement of psychiatric support systems (Stanley et al, 2016). Suicidality discussions can be neglected as a consequence of stigma around mental health.
A lack of data undermines accurate findings, so the extent of mental health problems are underestimated. Petrie et al (2018) studied data from 30 868 ambulance personnel during an international systematic review, and found prevalence of general psychological distress was 27%, among other statistics.
In the UK, a recent national consensus (Public Health England (PHE) et al, 2021) focused on the promotion of good mental health and prevention of suicidality within the ambulance service. While no specific driver of risk was identified, evidence indicated several factors that negatively impacted on welfare. The consensus therefore set out a shared commitment to achieving sustainable improvement in suicide prevention as well as to promoting a positive culture.
Critically analysing the available literature will enable unbiased extraction, assessment and challenge of current findings, and identify any data on suicide within the ambulance service that is lacking and unsubstantiated data. Objective interrogation of the methodology within the articles will identify limitations and provide an opportunity to explore additional research methods that could further improve detection mechanisms and support interventions.
There is clearly a requirement for additional research into the incidence of suicidality within the ambulance service, following broad recognition of an elevated risk (Milner et al, 2013; PHE et al, 2021). A systematic review of research on suicidality among frontline emergency services professionals found that up to 47% reported suicidal ideation (Stanley et al, 2016).
This narrative synthesis (Ryan, 2013) will offer a valuable contribution to current evidence, and critical analysis will provide a concise evaluation of the included reports and impartially examine their contents (Siddaway et al, 2019).
Paramedic-focused research has proliferated following the professionalism of this occupation within the last 20 years (Munro, 2016). The analysis of available data can test whether current assumptions are valid and delve into the dynamics underlying the results.
Methodology
A methodical literature search was conducted to identify peer-reviewed evidence. It began with a broad search of Google Scholar using the terms ‘paramedic suicide’ and ‘paramedic suicidality’.
Recurrent trends within the resulting articles were identified, enabling refinement and facilitating a second search to yield the most relevant results.
A search was carried out in 2021 of four electronic databases—the British Medical Journal, CINAHL, PubMed and Web of Knowledge, all of which focus on allied health professional research—for studies published between 2015 and 2020, to ensure that the most contemporary research was found.
Each database was searched using a variety of terms (Table 1) and permutations thereof following question refinement. Truncation (*) and Boolean operators AND and OR were used to enhance the search and expand the search criteria to include papers with variated nouns, thus increasing specificity (EBSCO Connect, 2022).
| Population | Paramedic*, Emergency Care Worker*, Pre-hospital Practitioner*, Emergency Medical Service* |
| Exposure | Intervention*, Prevention*, Program*, Protocol*, Pathway*, Referral* |
| Outcome | Suicid* |
The electronic search yielded a total of 85 papers, five duplicates were immediately excluded. Eighty titles and abstracts were independently screened using the included search terms, and 61 papers were excluded as their content was not relevant. Of the remaining 19, 16 were excluded as their content or outcomes were not relevant. Following this process, three papers were left for critical analysis. This process and the results are shown using a PRISMA diagram (Table 2) (Moher et al, 2009).
Analysis
These British (Mars et al, 2020) and international (Milner et al, 2017; Carleton et al, 2018) papers were assessed for internal and external validity. Their structure was examined for reliability and consistency, and it was determined whether results were generalisable across the workforce. In cases where all first responders were included, only data related to ambulance personnel were extracted. The quality of each included study was evaluated using the Critical Appraisal Skills Programme (CASP) (2018) qualitative checklist, and a risk-of-bias tool was used to identify whether the papers were credible, generalisable and balanced (Table 3).
| Study | Sampling | Methods | Reliability | Generalisability | Credibility |
|---|---|---|---|---|---|
| Milner et al (2017) | Sample of 10 422, gathered from national census and coroner files over 12 years. Good to reflect diverse workforce. Does not include retirees. No rationale for unreported data | Negative binomial regression, exhaustive method. No blinding mentioned. Data extracted then anonymised. Confusing identification of results. Took 5 years to collate data | Very subjective account of data. Very limited substantiative evidence to support accounts. Negative identification of facts, again with no explanation | Report identifies confounding variable, using the general population (which does not experience the same level of trauma) as a basis. Identifies delay in coronial process, so identifies under-reporting of suicide. Male-dominated results and discussion | Ambiguous statements throughout. Missing reference. Results and discussion points do not always match. Lack of clarity. Do not present any objective measure of stigmatism |
| Carleton et al (2018) | Limited explanation of missing data. Small total sample across emergency services national workforce. Uneven gender representation: 67.5% men/32.5% women. Only 3.4% of invited participants completed survey | Independent survey completed at home. Little to no ability to confirm responses. Ambiguous nature of survey questions. Took 1 year to collate data | Email invitation accompanied by support video. Significant consideration of contributory factors. Little evidence of justification for potential participants' inclusion. Mention of ‘unmeasured variables’ but no explanation | Locations of surveys published. Ability to find statistical significance across areas. 3.4% sample of invitees is a minimal sample group. Simple graph with all included variables missing from study. No inclusion of students or retirees | Very diverse list of references. Well documented evidence. Evidence of adjustment included throughout study. No mention of power calculations. Very important point: those who died by suicide were not included within the prevalence discussion |
| Mars et al (2020) | Eleven NHS ambulance trusts involved. Not all responded to data requests. National inclusion of coroner reports. No participant withdrawals; all data were submitted. No mention of power calculation. Inclusion of historical data | Review of records: coroner and employment. Men accounted for 73% of suicides, an unequal measure. Took 5 years to collate data. Good explanation of variables within studies | No inclusion of experience. No method explained to ensure that all data from 11 trusts were received. No inclusion of blinding methodology. Sickness absence was recorded. Assesses disparity in data. Speculation was used where evidence was scant | All data from the UK. Coroners' verdicts have been included, but these were unsubstantiated owing to logistics of death. Causal links made and discussed with evidence. Some discussion of proportional demographic (over-representation of men). Research funded by the Association of Ambulance Chief Executives | No inclusion of risk factors/causes. Statistical data only. Ambulance-specific, no other blue light providers involved. Identification of paucity of data. Comparison with general population |
Discussion
Paramedics are distinguished from the general public because they are frequently exposed to human tragedy (Fjeldheim et al, 2014). The included studies compared ambulance personnel broadly with the general population. Although this provides an indication of relative risk, some caution must be applied owing to differences between these two groups. The general population is less likely to encounter trauma as often (Knudsen et al, 2010; Enzenbach et al, 2019); therefore, comparing paramedics to industries that share similar occupational hazards would develop reliability, reduce confounding variables, increase objectivity and improve credibility (Sheridan, 2019; Lawn et al, 2020). So far, few studies have focused on suicidal behaviour within the ambulance service independently from other frontline providers, as is the case in the two hybrid papers, which reviewed data from frontline emergency and protective services (Milner et al, 2017; Carleton et al, 2018).
A plethora of research demonstrates the potential for psychological adversity for health professionals, following expansion of roles, increased workloads and burden on the service (Boyle, 2015; Williams et al, 2017; Grochowska et al, 2022). Terms such as ‘burnout’, ‘compassion fatigue’, and ‘moral injury’ are now prevalent among the healthcare literature base, indicating the need for enhanced recognition of vulnerability and effective intervention.
While the evidence base can establish the impact of stressful working environments in the main, there continues to be a dearth of paramedic-specific research (Williams et al, 2017), making it extremely challenging to adequately establish the incidence of psychological vulnerability. Research that focuses solely upon this professional group will enhance understanding, promote discussion, and validate the need for greater support.
The included reports found that in each of the countries studied, ambulance professionals had the highest incidence of suicidality across occupational groups within emergency and protective services.
Hird et al (2019) investigated the prevalence of suicide within UK ambulance trusts using data from the Office for National Statistics (ONS), and found that between 2011–2015, 20 suicides of ambulance staff had been registered by coroners. It should be noted that the burden of proof when reaching a finding of suicide was beyond all reasonable doubt, which significantly affects a true assessment of the problem, and may reduce the reliably of Hird et al's (2019) findings. However, in 2018, the standard of proof was changed to on the balance of probabilities (Appleby et al, 2019). The ONS has since reviewed suicide death figures, but cannot conclude that the change in standard of proof is responsible for a recent rise (ONS, 2020). It suggests instead that the factors behind this increase may be more complex, and that further investigation and monitoring is required to determine influencing variables more reliably.
One study (Milner et al, 2017) found ambulance personnel were at greater risk following higher degrees of stress; however, this was unsubstantiated and little to no evidence was presented to support this statement. In contrast, Carleton et al (2018) suggested that, despite a higher prevalence of suicidality within the service, the sample size was not large enough to show statistical significance or generalisability. Data sampling methods differed between the papers, and none could explicitly demonstrate reliability, owing to the significant lack of explanation regarding unreported data and small sample sizes. Markedly, the lack of exhaustive and robust sampling and gathering of data methods across the papers indicate that research with stronger methodology should be carried out. This appears to be the case with paramedic-specific research, as there are limited sources that offer valid, credible and dependable evidence to support and or refute such analysis.
Two studies (Carleton et al, 2018; Mars et al, 2020) used national databases to gather statistics—unbiased, well-known sources where data can be validated. Notably, Mars et al (2020) identified that their data were insufficient as their funding budget did not enable a member of the research team to travel to numerous locations to collect evidence. Despite this limitation, the report has included a proportional representation, and synthesis of the available outcomes has concluded noteworthy findings of risk stratification, causality and prevalence.
There is a significant scarcity of reports analysing variety in suicidality within the ambulance service. As such, an investigation into suicide attempts and events preceding suicide would perhaps improve understanding (Klonsky and May, 2014). Identifying and analysing the continuum of suicidality alongside associated factors is arguably an area in need of further examination to enable the modification of support services.
One paper (Milner et al, 2017) hones in on the method of suicide to distinguish rates between services. While this is a comparable statistic, not all suicides are recorded as such, which may therefore lead to inaccurate results. Negative binomial regression, a widespread linear model where the dependent variable is the frequency of the event (Sroka and Nagaraja, 2018), was also used to assess rate ratios. This method appears robust, as the discrepancy between mean value and variance in real-life data does not follow conventional statistical calculations (Sroka and Nagaraja, 2018). On balance, it seems reasonable to hypothesise that frequent exposure to traumatic events can increase the risk of suicidality (Walker et al, 2016), further supported by broader research into the prevalence of post-traumatic stress disorder and depression (Lawn et al, 2020).
All three papers identified that psychological damage was a recurring theme.
Men appeared to be at increased risk but this was not contextualised to the workforce demographic. According to the most recent data audited by the Health and Care Professions Council (2019), 27 415 paramedics were registered to practise within the UK. Of these, only 10 835 were men, who represent approximately 39.5% of the workforce. These figures suggest further analysis should be carried out to understand why men are at a higher risk, given that they make up a minority of the total workforce. Only one paper made any attempt to recognise that psychological differences between the sexes may have in part accounted for this disparity (Carleton et al, 2018).
Throughout all three included papers, recurrent occupational risk factors were identified. A non-exhaustive selection of these are erratic shift patterns, stigma and an inherent desire to help others at the cost of personal needs. Psychological risk factors are particularly significant, as these could provide opportune intervention points (Cromer-Hayes and Seaton, 2020; Lawn et al, 2020), yet there continues to be a distinct lack of empirical research focusing on the correlation between risks and suicide. Profound psychological damage was reported to cause social withdrawal and isolation which, in turn, had a negative impact on psychosocial relationships, raising the risk of further depression and stress.
None of the studies examined the role of psychosocial relationships on suicidal risk. The exclusion of such enquiries reduces the breadth of the results and leaves the likelihood of unanswered questions.
However, paramedicine carries protective factors that are not mentioned in any of the critiqued reports. Contextual evidence suggests that protective factors such as camaraderie and social support may reduce the risk of suicidality among paramedics (Stanley et al, 2016). Further evidence emphasises that a sense of purpose among personnel may further reduce risk (Dropkin et al, 2015). An individual who feels that their skills are important in the protection of others may be less likely to die by suicide (Stanley et al, 2016).
Nevertheless, these protective mechanisms can be overwhelmed in comparison with portentous risk factors (Dropkin et al, 2015; Stanley et al, 2016). An inadequate chance of rest and disrupted sleeping patterns are fundamental factors associated with suicidal ideation (Kalmbach et al, 2017; Galeano, 2019). Given this association, and the fact that shift work is an integral part of the job role, additional delineation of correlation between suicide and insomnia, particularly among paramedics, is required (Vallières et al, 2014; Stanley et al, 2016). A breadth of evidence suggests a causal link between inadequate rest and depression (Fjeldheim et al, 2014) which, in some cases, can lead to suicidal ideation (McCall and Black, 2013).
While the findings suggest that occupational risk factors potentiate suicidality, a psychological autopsy study of police officers between 2000 and 2010 did not conclude that traumatic incidents in the workplace were a leading theme (Rouse et al, 2015). Therefore, it could be argued that further investigation into this subject is vital to substantiate claims further.
It is well recognised that the paramedic work environment is a substantial contributor to negative physical and mental welfare (Cromer-Hayes and Seaton, 2020; Lawn et al, 2020; Sharp et al, 2020). Continued and frequent exposure to devastating events give rise to poor health, increased absence from work and decreased efficiency, evoking a causal link with morbidity (McCall and Black, 2013). Operational metrics, such as response times and extended shifts, also cause psychological strain. A report on risk factors for mental ill-health also highlighted that ambulance professionals felt vulnerable following an increase in aggression and abuse from patients (Dropkin et al, 2015). It recommended that trusts must identify risks and implement appropriate safety mechanisms and interventions.
An example of a preventive method is the provision of body-worn cameras for frontline professionals; this followed the publication of recent figures that identified a 32% increase in assaults over five years (College of Paramedics, 2021). While broadly this trial has been welcomed by staff, there are still some hesitancy and concern among professionals regarding their efficacy. So far, reports suggest that body-worn cameras aid in de-escalation but, with this trial still in its infancy, collation and analysis of findings are required to accurately elucidate whether this intervention is successful in improving staff safety and welfare.
The data do not provide any evidence on a link between length of service and increased risk, as the included papers did not include life-time suicidal ideation in their surveys. A failure to identify whether underlying concerns before employment as well as the exclusion of retirees could have provided an inaccurate representation of the problem.
Furthermore, anecdotal evidence implies that the transition of the paramedic role from a ‘job for life’ to a ‘job for now’ adds concern. The retirement age for paramedics is 7 years later than that of other emergency services professionals (Mangar Health, 2017; Unison, 2018). With growing evidence that suicidality is disproportionally higher within the ambulance service, perhaps pressure could be increased on the government to bring retirement ages into line. Such a campaign has been started by Matt Fisher, a long-serving paramedic with the London Ambulance Service (Unison, 2018).
Some evidence suggests that structured recuperation following traumatic events can reduce stigma and encourage people to feel more positive about accessing this (Adams et al, 2015; Dropkin et al, 2015). Yet the practicalities of this option can be questioned when anecdotal evidence suggests that ambulance trusts appear to be at their breaking point (Unison, 2015; GMB North West and Irish Region, 2019; NHS England, 2021). Recent surveys suggest that three in four ambulance staff require additional support to maintain their physical and mental health. Increased pressure, which was exacerbated during the pandemic, has caused an escalation of low morale and desperation (Mind, 2016; GMB North West and Irish Region, 2019). Although this finding is not directly related to suicidality or the included papers, it does suggest that rising pressure and demand upon ambulance clinicians can have a myriad of negative impacts. While call volumes are at their highest level (Association of Ambulance Chief Executives (AACE), 2023), clinicians may feel reluctant to seek support as operational pressures prohibit the opportunity to do so.
Further reports also recognise that supported reflection can significantly decrease detrimental impacts on psychological welfare (Paterson et al, 2014). Early intervention is fundamental to deter and prevent isolation, and some studies show that the cultivation of support networks at this stage can significantly reduce risk (Adams et al, 2015). Yet the debate as to when is best to offer such services continues (Paterson et al, 2014; Flannery, 2015).
Evidence shows that peer focus groups and psychological first aid for early intervention and treatment appear to have the most support (Rice et al, 2014; Flannery, 2015). The Association of Ambulance Chief Executives (AACE) has developed a programme where practitioners are trained in mental health first aid (Parry, 2019). This training enables clinical staff to recognise signs and symptoms of deterioration in their colleagues and offer compassionate and sensitive support. Parry (2019) recognises that expecting paramedics to remain untouched by frequent exposure to suffering and loss is unrealistic. Therefore, the development of this programme across ambulance services is an attempt to proactively engage in staff welfare (Sharp et al, 2020).
The transition of paramedicine from a vocational, male-dominated profession to a graduate, registered occupation with increases in female recruits has in part changed the contemporary manner in which welfare services are provided (Donnelly and Bennett, 2014). Developing health services during such cultural change can prove complex for any institute while maintaining efficiency to meet ever-increasing service demands (Rice et al, 2014; Larsson et al, 2016).
Current strategies to support those working on the front line attempt to dispel the stigma and shame that can be associated with mental health problems and encourage staff to seek support (Rice et al, 2014; Adams et al, 2015). Since 2015, Mind (2016) has developed a Blue Light Programme, through which support is offered across the emergency services. Following a survey where 86% of respondents identified that stronger emotional support mechanisms were required and 87% said that the absence of a positive, coherent mental health campaign discouraged openness and honesty, Mind now has signed up more than 50 emergency employers and nine national associations to the Blue Light Time to Change Pledge. This commitment encourages providers to raise awareness, challenge stigma and help staff to engage with support services.
The three included studies scrutinised suicidality among paramedics; Milner et al (2017) and Mars et al (2020) carried out retrospective investigation of existing statistics. The inclusion of longitudinal studies in future research may enable a clearer indication of risk and facilitate improved interventions. The development of a cohesive mortality record would improve risk stratification as well as identify individuals at heightened risk. Additionally, the inclusion of students and retirees would help develop a fairer representation and understanding into the scope of the problem (Lanza et al, 2018).
Notably, the three included papers do not examine in detail whether current intervention strategies are effective in reducing suicidality. Contextual literature also suggests that there is a dearth of research into effective intervention mechanisms (Hom et al, 2015). The successful mitigation of suicidality and a reduction of its prevalence require easy access to appropriate interventions (Bruffaerts et al, 2011; Hom et al, 2015).
In summary, this review sought to explore suicidality within the ambulance service, and draw attention to the profound concerns of psychological vulnerability among the emergency workforce. The three papers included have begun to explore the prevalence of suicidal ideation and suicide and have highlighted areas in need of additional evidence and provided a base on which to develop and enhance understanding.
Awareness remains inadequate and, anecdotally, this may be because operational and organisational burdens may prohibit adequate financial support for this. It is well documented that the NHS is under more pressure than ever before and investment in mental and psychological wellness of its employees must not be neglected.
The papers have attempted to synthesise current research into the prevalence of suicidality, and success of interventions in the ambulance service.
Further research applying robust methodological strategies with improved rigour are required to elevate the current understanding.
Limitations
These studies, which provide an informed foundation for further research, have several limitations.
The samples chosen for each study may have fairly represented the historical workforce; however, with a rapid change in personnel demographics, and data suggesting that approximately 60.5% of the service are women, future studies require adequate proportional representation to sufficiently reflect current staffing.
The response rate within each report did not adequately identify withdrawals and the reasons for these. In Mars et al (2020), not all trusts responded to the request for information, which could potentially result in an underestimation of the true figure of suicidality.
In addition, the validity and reliability of independently completed online surveys can be ambiguous (Lenderink and Zoer, 2012; Safdar et al, 2016), which could undermine consistency. A lack of complete data may mean the prevalence of mental instability within the ambulance workforce is underestimated. A recurrent theme across these surveys is the concern of stigmatism following disclosure. This may have caused under-reporting, although anonymity is likely to have reduced inaccuracy in this regard.
Finally, while the standard of proof for coroner verdicts has changed, data from these may continue to be inexact.
High prevalence rates across the relatively small sample justify further robust assessment. Future research should include the assessment of lifetime suicidal ideation, which would indicate the correlation between employment in the ambulance service and suicide. Larger samples would also produce broader findings, improving reliability, validity and generalisability.
Conclusion
This synthesis has found that while data exist on the prevalence of paramedic suicide, a lack of transparency and precise data collection methods hinder an accurate reflection of the issue in the UK and elsewhere.
Ambulance professionals are regularly exposed to devastating and traumatic events because of the nature of their role. The evidence within this report sufficiently indicates that organisational and occupational issues are damaging to mental and physical welfare. The data further show there is a correlation between frequent exposure to such incidents and an increased risk of mental health disorders, which, if left untreated, can lead to suicidality. Additional associated risk factors were found to include relationship problems, prolonged sickness absence and sleep disturbance.
Further research with larger participant groups within the ambulance service is required to broaden the understanding of this concern and develop strategies to safeguard wellbeing. The exploration of thoughts towards seeking help and the motivation triggering this action would promote early identification of staff at risk.
Subsequently, collaborative development of intervention programmes would help to reduce stigma and the incidence of suicide. Following suicide, psychological autopsies could begin to address absent data and provide the details that are so often lost during this distressing time.
Finally, the development of a mandatory trust-wide reporting system on suicide would encourage a transparent integrated policy as well as maintain a high profile.
Overall, the results across the three papers, supported by relevant broader contextual evidence, suggest an alarming increase in mental health issues experienced by paramedics.
There is a growing need for nuanced and comprehensive policies to support a broad spectrum of personnel. Everybody is responsible for ensuring that barriers of stigma do not prevent clinicians from seeking the support needed to prevent the progression of suicidal behaviour. Reducing the incidence of suicidality within the ambulance service is a global responsibility and must be prioritised.