As pre-hospital management and care has advanced considerably throughout the decades, indeed so has the many and varied pressures associated with front line duties. In addition to sometimes extremely complex and challenging pharmacological, physical and mental health interventions, frequently required time sensitive critical decision making regarding not only scene management at major incidents but also relating to additional lifesaving interventions, pathway and referral use, and ultimately patient destination are a necessity at many incidents.
These factors, coupled with general work pressures such as unsociable shift patterns and training commitments, everyday stresses like health or relationship problems, occasionally culminate into life-changing conditions within the ambulance and pre-hospital care community. Unfortunately, these problems have been seen to affect fellow colleagues and friends more increasingly in recent years, resulting in a negative influence on not only performance, but moral, motivational and general well being. These firsthand observations are also mirrored by both media (Kirk, 2015) and ambulance union reports (Unison, 2015), and backed by various statistics offered by The Workforce and Facilities Team Health and Social Care Information Centre (2014). This suggests that ambulance service sickness levels throughout the UK have steadily risen since at least 2009, and are far higher than all other NHS organisations regarding sickness incidents.
This article will be used to facilitate exploration and discussion regarding when and how these everyday pressures metamorphose into more sinister conditions such as Post Traumatic Stress Disorder (PTSD). Also consideration will be given to what is being done to alleviate such happenings and the support and treatment developments in place to support affected front line ambulance staff. This hopefully will increase understanding of these sometimes overlooked issues increasing the chance of identifying problems early and helping to provide supportive aid and information where possible.
Method
A methodical literature search using well known related databases was undertaken to acquire access to a sufficient information pool, enabling the exploration and formulation of practice recommendations. Key databases searched included the Cumulative Index of Nursing and Allied Health Literature (CINAHL Plus), Medline, Psych info, British Nursing Index (BNI), Allied and Complimentary Medicine Index (AMED), Excerpta Medica database (EMBASE), Health Business Elite (HBE), Health Management Information Consortium (HMIC) and PubMed.
Other information gateways used include Athens, The Cochrane Library, The York University Library Literature Search, The Kings Fund, NICE Guidelines and The Royal College of Psychiatrists, whilst specific journals such as The Journal of Paramedic Practice, The Evidence Based Mental Health Journal (EBMH), The Emergency Medical Journal (BMJ), British Journal of Mental Health Nursing and The international Journal of Emergency Mental Health have been scrutinised for additional sources of data. Information pre-2000 was excluded to keep the evidence base as up-to-date as possible, thus ensuring ideas are based upon current theories, statistics and treatments.
Understanding PTSD
Although many mental health conditions share similar signs and symptoms, PTSD has several key symptoms which set it apart from more common conditions. These similarities can make an accurate diagnosis difficult, by confusing the overall clinical picture. Duffy (2010) highlights these thoughts by suggesting that due to similarities to, for instance psychotic indicators, PTSD can often be misdiagnosed causing delays and difficulties with the correct treatment plan offered. This is, in part, due to the lack of clinical information available to accurately differentiate the two, which is significant as treatment for psychotic conditions such as schizophrenic spectrum disorder or bipolar disorder and PTSD are fundamentally different.
The National Institute for Health and Care Excellence (NICE, 2005) tells us that broadly speaking, the symptoms brought about by PTSD are split into three clusters and include re-experience, avoidance and hyper-arousal. NICE (2005) continues to explain that PTSD sufferers relive traumatic aspects experienced in the past in sometimes very detailed ways causing distress, frequently leading to intense psychological and physiological outcomes. Re-experiencing symptoms could take the form of physical stimuli such as pain, noise or smells for example, causing an unconscious link to past events, nightmares and detailed flashbacks with spontaneously emerging intrusive images and thoughts being commonplace.
Mind (2013) adds that avoidance symptoms relating to PTSD are an attempt by the patient to ignore or disregard traumatic memories and experiences in a bid to evade possible reminders of triggering events. This can be achieved in several ways including avoiding people associated with the event in question or timings surrounding the event, often leading to social isolation, and the overuse of alcohol or drugs in an attempt to help forget. Sufferers can find it difficult to express affection and try to keep busy in an attempt to reduce the chance of negatively associating thoughts and triggers. Hyper-arousal, as the name suggests, is the general increase in a person's anxiety levels and an altering in normal arousal states which can result in emotional outbursts and concentration abnormalities. Patients may have difficulty in relaxing, and be more ‘on edge’, which often leads to insomnia and general irritability (NHS Choices, 2015).
Prevalence
In order to appreciate how vast a problem mental health is becoming when exclusively linked to emergency services staff, data around relevant prevalence must be explored. MIND (2016) demonstrates a troubling state of affairs by presenting data from an online survey of over 1 600 participants, from the ambulance, police, fire and search and rescue services in the UK, which suggests that whilst 63% of people had thought about leaving their job, 27% had contemplated suicide due to stress and problematic mental health. Furthermore, 92% of respondents had experienced poor mental health at some point with an unprecedented 62% of front line staff receiving treatment for a specific mental health problem such as depression, anxiety disorders, OCD, PTSD, bipolar disorderor schizophrenia during their working life.
As ambulance trusts throughout the UK struggle to keep enough staff on the road to match the ever increasing patient demand, how is the prevalence of acquired mental illness affecting service suitability and patient safety levels? Although specific details of the reason behind absentees were unavailable, The Workforce and Facilities Team, Health and Social Care Information Centre (2015) state that statistics in 2015 show sickness rates throughout the NHS on the rise with ambulance staff having the highest average sickness absence of 6.78% compared to the lowest, nursing, midwifery and health visiting learners at 1.22% with ambulance trusts in general having the highest average sickness rate of 6.44% at organisation level, compared with the clinical commissioning groups, the lowest, at 2.78%. To add further context, Blaber (2014) state that out of every industry in Britain, healthcare work carries the greatest risk of work-induced psychological stress while Hegg-Deloye et al (2014) add that for paramedics, these findings are reflected internationally, too.
Berger et al (2012) suggest that studies of the three major emergency services: police, fire and ambulance, showed that the ambulance service had a higher estimated PTSD prevalence than other services due to greater pressures experienced (Young and Cooper, 1995) and a greater frequency of emergency calls than the police and fire services combined (Di-Fiorino et al, 2004). With adverse mental health conditions associated with frontline staff on the rise, information regarding absentees' cause is very difficult to obtain. Any discussion surrounding this subject comes from media interest or anecdotal evidence, while the NHS and regional ambulance services keep statistics outlining the reason for absence seemingly distant from public scrutiny. Kirk (2015) shows that from a freedom of information request submitted to the NHS, figures given show a dramatic increase of absence taken due to work related stress, rising 28% from 2012 to 2014 with the biggest increase in the East Midlands ambulance service of a 142% during the same period of time.
Available support
Utilised by many ambulance services Trauma Risk Management (TRIM) is a peer led psychological risk assessment tool used with those exposed to traumatic events by trained, but not always medical staff, in order to identify those at greater risk of developing psychological problems in a bid to appropriately intervene and promptly sign-post potential self help and support services (Hunt et al, 2013). Everly et al (2000) suggest that psychological debriefing is a helpful way of reducing negative psychological impact following a critical incident. Mitchel (1983) add that this is only the case if it is undertaken by specialists or trained individuals within 24–72 hours of the incident. However, a Cochrane review published in 2002 and updated in 2006 by Rose et al highlights a lack of evidence that backs this method. This review calls for the practice to cease, as recalling events could bring about secondary psychological trauma.
The East Midlands Ambulance Service (EMAS) was one of the first services in the country to sign up to the Blue Light Pledge developed by Mind, according to NHS Employers (2016). Mind (2016) explains that although signing up to the Blue Light Time to Change Pledge is not a mark of quality, accreditation or endorsement, it is a pledge to show commitment within a particular service, whether ambulance, police, fire or search and rescue to tackle the stigma associated with mental health problems while actively supporting positive mental wellbeing and developing pro-active supportive systems.
EMAS also endeavoured to launch new initiatives called peer 2 peer (PSP) and Pastoral Care Workers Service (PCW) in 2014, in order to give peer support and signpost employees to further support services. PCW volunteers also help the chaplain with staff's spiritual support needs. Seddon et al (2011) suggest that a collaboration between clinicians and chaplains is invaluable in order to identify mental health problems. Chaplains are well suited to counselling individuals due to their unique skillset, providing mental health and counselling knowledge is up to date and religious beliefs do not cause confusion or bias with the thought processes of a mental health confidant. By also providing all frontline staff with support handbooks, chaplaincy access, weekly reminders of support options, East Midland Ambulance staff are able to self refer if needed, while also having trained colleagues to look out for mental health red flags (NHS Employers 2016) providing a well rounded mental support scheme.
Future possibilities
As always, technology plays a huge and invaluable part in future development in all areas, with health management being no exception. With modern mobile phones, great efficiency, connect with anyone via text, email or online application coupled with easy access to computers and laptops either in a work or home environment, contact and communication is now often immediate, cost effective and readily available in most cases. Research, studying answers given following interviews with people either in charge of developing digital strategies and services or responsible for employees wellbeing from Bupa, AXA PPP, Vitality, Cigna, South Western Ambulance Service, The University of Wolverhampton, The Edinburgh Napier and Aston University by Do Something Different and The University of Sussex (2016) suggests that digital technology will have a major part to play in employee wellbeing by 2020, preventing conditions such as stress linked mental disorders, utilising applications and health trackers, both on and offline providing staff support to manage their own wellbeing.
With the NHS Five Year Forward View (NHS, 2014) committing to improving developments in digital technologies within its organisation, Do Something Different and The University of Sussex (2016) add that with an ever changing workforce, digital technology is invaluable as the ambulance service's coverage consists of vast areas. They also suggest that digital investment offers greater flexibility and choice of technology, which is key in motivating individuals to participate in truly tailored interventions while offering autonomous self management and efficiency, 24 hours a day, 7 days a week in any location, giving well rounded support and promoting action and interactivity rather than static information and data.
By merely touching upon plans to develop supportive staff wellbeing measures, it is clear that although most services are pro-active with regards to the advancement of related developments, more work in this area is needed. Spending relating to this subject should be thought of as investment rather than expense, although it is accepted that service budgets are stretched periodically. By highlighting advances and advantages in digital service development, connections between future technological investment and front line ambulance staff welfare can be made, drawing attention to the crucial role that this advancement could potentially play in future outcomes and forward planning.
Other potential support ideas
Further afield in Australia, several responder organisations from various states and territories have got together to produce a collaborative framework committed to the mental health and wellbeing of responder organisations. The Good Practice Framework for Mental Health and Wellbeing in First Responder Organisations (Beyondblue, 2016) is a collaborative programme represented by police, ambulance, fire and rescue and state emergency services coupled with frontline operational, union, legal, clinical and academic advisers, and support from The Commonwealth Departure of Health and Ageing. They focus on changing the public perception of mental health relating to front line staff and seeking commitment for change from leaders, politicians and employer organisations.
Aiming to provide a core tailored framework for all frontline services, it is recognised that this proposed approach will combat absenteeism, poor moral, grievances, conflict disability, injury and performance problems (Standards Council of Canada, 2013) while promoting positivity about mental health, increasing productivity and helping to recruit and retain staff (Instinct and Reason, 2014). Recognising the fact that one approach will not suit all organisations, the framework acts to guide organisations and advise when needed, to allow each service to tailor their individualised programme to fit their own unique pressures. The guide influences schemes to incorporate the setting up of working groups. They also facilitate enlisting help from volunteers; reviewing existing mental wellbeing policies and procedures; determining action plans and promoting discussion within the service. The purpose of these activities is to break down barriers surrounding mental health stigma and promote to staff ongoing and developmental plans within the service that showcasie the organisation's commitment.
Exploring support programmes in other countries allows us to spot different approaches. This helps to develop ideas of potential improvements within the ambulance service. Promoting schemes as long-term gives ensures that the organisations are serious in their commitment, adding to staff-confidence. The involvement of a wide and varied task force as in the Beyond Blue (2016) scheme provides an invaluable skill set, using a multi angle approach, in order to provide a comprehensive framework providing all associated services with a strong foundation to base onward development.
Recommendations for practice
Funding and fundraising.
One difficulty encountered in the quest for stringent welfare services and training is that of adequate funding. Sufficient funding associated with service improvement and staff training, including course development and operational flexibility, would allow staff to be released for training, enhancing resilience throughout the organisation. To secure funding for projects including wellbeing and mental health services, it may be necessary to ‘think outside the box’ as conventional NHS funding is stretched increasingly thin (The Kings Fund, 2016). For example, by establishing charities such as the Yorkshire Air Ambulance (YAA, 2016), or allowing sign written sponsorship on vehicles, additional financial support could be gained. Events organised by services such as sponsored walks, sporting events and social events could also increase additional funding and simultaneously raise the profile of mental health matters acting as a catalyst for open dialogue on the subject.
Training and education
Following review of the literature, it is believed that resilience and awareness training should be given with every induction, with follow-up refresher training offered annually. Incorporating education packages early in a person's career and by offering a follow-up maintenance programme, an open minded culture, improved knowledge base, reduction in stigma and discrimination surrounding the subject of mental illness can be sought, achieved and maintained. It is hoped that these initiatives would help staff to open up about any problems they are experiencing, whilst aiding the identification of problematic symptoms manifesting due to critical events. Health Promotion Cornwall and Isles of Scilly (2016) suggests that training of this type can help participants contemplate signs, symptoms and different elements of mental illness while providing information on how to help themselves and others, additionally highlighting responsibilities of employers and support in the workplace.
Investment in Self Help Flexible Mobile Applications and Technology.
To motivate and inspire employees to monitor, maintain and take responsibility for their own wellbeing, user friendly, self service health tracking systems and applications should be developed. This would both promote the benefits of good health mentally and physically, while allowing improvements to be obtainable and well documented (Do Something Different and the University of Sussex, 2016). There is a strong possibility that this will indeed have some uptake in the future as large parental organisation such as the WHO (2013) and the NHS (2014) are both recommending and endorsing the use of similar technology. The promotion of these tools could be by email, news letter or in-house training. other well known social networks could also be utilised, reducing overall costs due to them being freely accessible.
Peer Support
With mental health crisis occurring at any time, support needs to be flexible and ample. Individuals who have undergone training in mental health related peer support and post incident debriefing using TRiM should be sourced from all roles and groups within the service if possible. This is likely to help reduce stigma, promote open discussion regarding, not only adverse symptoms but problems in general and include all groups in a bid to reduce discrimination by embracing all employees. Both anecdotal evidence and literature reviewed suggests that post incident debriefs and trauma management tools are successful only when the persons involved can have a frank open discussion, and when completed thoroughly and with purpose and empathy. By using all ambulance service staff if possible rather than external services or solely managerial roles to carry out such assessments, a good bond is more likely due to shared links with the unique, ambulance work specific problems, further motivating an open exchange (Kitaeff, 2011).
The Blue Light Pledge.
A common factor in most emergency service support is the signing of Minds Blue Light Pledge. By signing the pledge employers receive help with the development of action plans, are provided with advice around the maintenance and advancement of services, and are given examples of already successful schemes utilised by other member organisations, making it an invaluable and inexpensive way for the ambulance service to access tried and tested support options (Mind, 2016).
It is recognised that mental health services are and have been implemented for some time in the ambulance service. Unfortunately, literature surrounding the study of results related to the new services is lacking. More research within this area would allow a more evidence based progression and efficient development of future support. This is likely to lead to improved, cost-effective schemes.
Conclusion
By analysing existing available support and treatment, future development and improvement and lessons learnt from elsewhere, thoughts around evidence based improvements and best practice can be assembled. Although mental health services are available in all ambulance services, these should be improved upon to maintain a strong, capable and resilient workforce that is able to cope with traumatic experiences as well as everyday stresses. Services need to think of support utilising a more holistic approach rather than that of a cold and impersonal paperwork exercise or chore. Spending in this area must be thought of as an investment rather than an expense, as a happier, healthier workforce will help productivity by reducing absence and impressing a more professional attitude towards frontline duties. More importantly, although unique pressures exist in the ambulance service, people from all groups and cultures have the right to uniquely tailored, evidence based, empathic care, whether they are employees, colleagues, friends, family or passing strangers.