When an individual contacts 911 because of a medical emergency, he or she expects to receive an ambulance staffed with highly trained, professional prehospital practitioners. These health professionals should arrive quickly then rapidly, safely and efficiently transport the patient to the emergency department and/or provide treatment and care on the scene.
As prehospital providers, paramedics continually face unexpected situations and are exposed to some of the worst situations imaginable. They also work long shifts, often ranging from 12–24 hours at a time in parts of the United States and potentially even longer shifts internationally (Pacheco, 2023).
A combination of encountering unexpected situations, long shifts and witnessing human distress and tragedy can have lasting effects on the psyche of these health professionals.
Numerous studies have addressed the physical effects of 24-hour shifts in emergency medical services (EMS) on paramedics; however, there is limited research focused on their mental health regarding anxiety. The purpose of this study was to examine and compare anxiety levels in paramedics who work 12-hour shifts with those working 24-hour shifts.
This literature wreview concerns mental health conditions paramedics may experience after working their required shifts. It examines anxiety and the types of anxiety disorders that are recognised by the National Institute of Mental Health (NIMH). Finally, it discusses risk factors and treatments for anxiety disorders.
Anxiety
Anxiety is an abnormal and overwhelming sense of apprehension and fear, which is often marked by physiological signs such as diaphoresis, hypertension, palpitations and an increased pulse. (Merriam-Webster Dictionary, 2023). NIMH (2023a) notes that occasional anxiety is a normal part of life, experienced by many before taking a test or making important personal or professional decisions. For some, this normal anxiety can escalate into an anxiety disorder (Sofianopoulos et al, 2012) and this can interfere with an individual's job performance, relationships and general daily life (NIMH, 2023a).
Generalised anxiety disorder, panic disorder and social anxiety disorder are all anxiety disorders recognised by the NIMH (2023a).
Symptoms of generalised anxiety disorder include irritability, becoming fatigued easily, muscle tension, feeling on edge and difficulty concentrating. Symptoms of panic disorder include sudden and repeated attacks of intense fear, intense worrying about when the next panic attack may occur and fear of or avoiding places where panic attacks have occurred. Social anxiety disorder symptoms include feeling highly anxious about being with or talking to others, feeling very self-conscious in front of other people, fear of being judged by others, avoiding crowded places, difficulty in making or keeping friends and feeling nauseous when other people are around.
All three anxiety disorders share the following risk factors:
Stress
The NIMH (2023b) defines stress as the brain's response to any demand. Some people can cope with and recover from stress more effectively than others. Individuals may experience stress from sudden changes, traumatic events or routine occurrences such as sitting in traffic (NIMH, 2023b).
The American Institute of Stress reports that stress can increase productivity up to a certain point. However, once an individual reaches a particular point of excessive stress, productivity is dramatically decreased (Marksberry, 2011).
Occasionally, stress can be helpful instead of harmful. Short-term stress can have protective and beneficial effects (NIMH, 2023b). Short-term stress can activate the body's fight or flight response by activating the sympathetic nervous system of the body (NIMH, 2023b). Short-term stress can also activate and increase the body's immune system. (Goldman, 2012).
Chronic stress is generally considered a negative condition. During chronic stress, the body releases the same chemicals as it does during short-term stress but over a longer time period. This can have a cumulative effect and can cause a weakening of the body's immune system. It can also disrupt the digestive and reproductive systems (NIMH, 2023b). Chronic stress has also been shown to accelerate the progression of cancer by decreasing the body's immune response (Goldman, 2012). This connection of mental to physical symptoms can result in an overall decrease in health.
Emergency medical services
EMS are comprised of highly trained and specialised medical personnel. The highest level and most advanced providers in EMS are paramedics.
Paramedic programmes around the world vary in length from 8 months to 4 years, and cover anatomy and physiology, cardiology, pharmacology, traumatic emergencies, obstetrics and gynaecology, paediatrics, geriatrics, patients with special needs and numerous advanced medical procedures and treatments (University of California, Los Angeles (UCLA) Center for Prehospital Care, 2014). Paramedics are prehospital practitioners who are required to access, rescue, assess and treat their patients as quickly and efficiently as possible. (Hegg-Deloye et al, 2014). To achieve this, they must expose themselves to a range of physical and psychological stressors on each call.
Many prehospital providers report being exposed to traumatic events and experiencing excessive stress in their job (Donnelly 2012). This constant exposure to stress and tragedy takes a toll on the paramedics who strive to make a difference in their patients' lives. In one study, EMS professionals in the United States had a higher rate of early retirement. The main reason cited for this was a mental or physical illness (Bentley et al, 2013).
According to the Bureau of Labor Statistics (BLS) (2022), emergency medical technicians and paramedics have one of the highest rates of injuries of all occupations. The BLS says the reasons for this include the high physical demands of the job, exposure to contagious diseases and viruses, and injuries caused by combative patients. The BLS (2022) also reported that the average salary for a paramedic in 2018 was $34 320 per year and that some emergency medical technicians and paramedics worked >40 hours per week.
Because emergencies can arise at any time, EMS agencies and their practitioners are available 24 hours a day, 7 days a week. To ensure the public is always protected, many paramedics work 24-hour shifts. This often requires them to go against their natural biological sleep-and-wake cycles if they are forced to be awake during most of or the entire shift.
These shifts can be associated with significant fatigue, performance impairment and negative health outcomes among paramedics. Research has suggested that paramedics who work 24-hour shifts use more annual leave than those who work 12-hour shifts (Sofianopoulos et al, 2012). In addition, 24-hour shifts are associated with increased burnout, job attrition and negative health outcomes such as anxiety, depression, headaches and gastrointestinal illness (Paterson et al, 2014). Previous studies have reported a higher rate of medication errors and driving accidents involving paramedics with an increase in fatigue. (Sofianopoulos et al, 2012)
One study followed a 26-year-old male paramedic participant who worked 8-hour shifts and 24-hour shifts. It found that, even though the participant had the same number of hours of sleep before both the 8-hour and 24-hour shifts, he ranked the fatigue, sleepiness and difficulty concentrating higher after the 24-hour shift than after the 8-hour shift. He received ample amounts of sleep during the 24-hour shift and the unit hour utilisation during the 24-hour shift was 0.05 compared to a unit hour utilisation of 0.39, with little downtime for sleep during the 8-hour shift (Patterson et al, 2016). Unit hour utilisation was calculated by dividing the total number of calls by the total hours that a fully staffed and equipped ambulance is available for calls (Fitch and Associates, 2012).
Stress, depression and anxiety in the EMS practitioner
A study in the United States by Bentley et al (2013) examined the prevalence and severity of depression, anxiety and stress among nationally certified EMS professionals. It assessed whether there was a difference between individuals who were experiencing depression, anxiety or stress and those who were not. Out of 34 340 EMS professionals, 6% were depressed. Paramedics who worked in county, municipal or private services, and paramedics with >16 years of experience were at a higher risk for depression.
In addition to their findings on depression among paramedics, the authors discovered that roughly 6% of nationally certified EMS professionals were experiencing anxiety; most of them (94%) had normal anxiety scores. EMS professionals who had above normal anxiety scores were most commonly experiencing moderate anxiety (2.7%). Married EMS professionals were less likely to experience depression and anxiety than those who were divorced, widowed, separated or who had never been married (Bentley et al, 2013).
In a mental health study involving a survey of 560 Australian prehospital providers, a significant amount of mental health issues were identified. Ten per cent of respondents reported clinical levels of depression, and 22% reported clinical levels of anxiety. Rural paramedics experienced higher levels of depression, fatigue and anxiety. It was estimated that 20% of prehospital personnel might have poor mental health (Courtney et al, 2013).
Acute and chronic stress may raise the risk of cardiovascular disease. The amount of stress experienced by paramedics can be assessed by measuring cortisol and catecholamine levels. Paramedics typically have higher levels of stress hormones on the days they work than on the days they are not working. Additionally, post-traumatic stress disorder, sleep disorders and obesity are prevalent among emergency workers (Hegg-Deloye et al, 2014).
Methods
The purpose of this study was to determine whether there was a difference between anxiety experienced by paramedics who worked 12-hour shifts and those working 24-hour shifts. The mental health of EMS practitioners has long been neglected in the literature, with most studies focusing on the physical consequences of shift length on them. This study measured anxiety experienced by paramedics using the Beck Anxiety Inventory (Beck et al, 1988).
Upon approval of the Western Carolina University Institutional Review Board, the Beck Anxiety Inventory and a demographic survey were distributed at Greenville County EMS (South Carolina, US), Henderson County EMS (North Carolina, US) and Laurens County EMS (South Carolina, US). The demographic survey asked questions regarding certification level, education level, employment status, additional jobs, marital status, children, age and sex of practitioners working 12- and 24-hour shifts. Employees who work 24-hour shifts were physically at work and able to respond to calls over 24 hours then have 48 hours off before returning to work. Employees on 12-hour shifts worked a modified DuPont shift schedule with rotating nighttime and daytime 12-hour shift schedules.
The Beck Anxiety Inventory and demographic survey packet were distributed over a 1-month period in 2018 at the participating agencies. Completion of both was voluntary. The surveys were given to a contact person at each agency, who randomly distributed them to paramedics then collected completed surveys in sealed envelopes. The confidentiality of respondents was respected.
The Beck Anxiety Inventory was used to measure anxiety levels through answers to 21 items that are a subjective description of personal, somatic or panic-related symptoms of anxiety. Each item was rated on a scale of 0–3. A rating of 0 selected meant the respondent had not been bothered by the symptom described in the past month. A rating of 1 corresponded to being mildly bothered by the symptom in the past month, a score of 2 corresponded to being moderately bothered and a rating of 3 corresponded to being severely bothered (Beck et al, 1988)
Any Beck Anxiety Inventory overall score of ≤15 was assigned a 0. A score ≥16 was assigned a 1. This grouped those in the categories of moderate anxiety (scoring 16–25) and severe anxiety (score of 26–63) together.
Data collected were entered into Microsoft Excel for Mac 2011, and these raw data were then imported into IBM SPSS version 25. A binary logistical regression analysis was carried out to determine whether any results met criteria for significance and to determine the odds ratio for categories that did reach significance.
Inclusion/exclusion criteria
A convenience sample of practitioners who held a valid paramedic certification in North Carolina and/or South Carolina and who worked full time at Greenville County EMS, Henderson County EMS or Laurens County EMS were included in this study. Those who did not have valid paramedic certification and did not work full time at any of these organisations were excluded.
The smallest of the EMS using only 12-hour shift systems surveyed was Henderson County EMS. Henderson County EMS is located in the mountains of Western North Carolina and is responsible for a population of 109 540 over an area of 375 square miles. It has 56 full-time employees who work 12-hour shifts and responds to approximately 13 500 calls per year.
Greenville County EMS had the highest call volume of all systems surveyed, responding to approximately 60 634 calls in 2015. Greenville County EMS is located in the Upstate of South Carolina and is responsible for a population of 474 266 over 795 square miles. Greenville County EMS has 195 full-time employees who work 12-hour shifts.
Laurens County EMS is also located in the Upstate of South Carolina. Laurens County EMS was the smallest system surveyed, and the only one included that used 24-hour shifts. Laurens County EMS has 34 full-time employees and 17 part-time staff. Laurens County EMS is responsible for an estimated population of 66 533 people and a 721 square mile area.
Participant protection
The survey packet included information on how the Beck Anxiety Inventory, demographic survey and consent form would be distributed, collected and kept confidential.
Additionally, it gave advice on accessing psychological assistance from a national suicide prevention helpline, doctor, mental health professional, or spiritual advisor. The statement stated: ‘Should you require psychological assistance, you are urged to contact the National Suicide Prevention by calling Lifeline at 1-800-273-8255 or seek help from your family physician, mental health professional, or spiritual advisor.’
Results
Out of the 99 Beck Anxiety Inventory and survey packets distributed among the three services, 78 (79%) were completed and returned. Of the 78 respondents, 49 worked 12-hour shifts and 29 worked 24-hour shifts (Table 1).
| Data point | Frequency |
|---|---|
| Average length of current employment | 6.51 |
| Median length of current employment | 5 |
| Average years full time | 9.05 |
| Median years full time | 7.5 |
| Additional jobs: yes | 42 |
| Additional jobs: no | 36 |
| Average age | 33.67 |
| Median age | 32 |
| Sex: male | 47 |
| Sex: female | 31 |
| Marital status: single | 21 |
| Marital status: married | 46 |
| Marital status: divorced | 11 |
| Marital status: widowed | 0 |
| Average number of children | 1.95 |
| 12-hour shift | 49 |
| 24-hour shift | 29 |
| Race: American Indian | 1 |
| Race: Asian | 0 |
| Race: African American | 1 |
| Race: Hispanic or Latino | 1 |
| Race: Native Hawaiian or Pacific Islander | 0 |
| Race: white | 72 |
| Race: not available or other | 3 |
| High school diploma | 28 |
| Associate's degree | 35 |
| Bachelor's degree | 14 |
| Master's degree | 1 |
| Doctoral degree | 0 |
| Average number of calls per 12-hour shift | 5.91 |
| Median number of calls per 12-hour shift | 6 |
| Average hours of sleep before 12-hour shift | 6.06 |
| Median hours of sleep before 12-hour shift | 6 |
| Average number of calls per 24-hour shift | 11 |
| Median number of calls per 24-hour shift | 12 |
| Average hours of sleep before 24-hour shift | 7.05 |
| Median hours of sleep before 24-hour shift | 7 |
| Minimal anxiety | 57 |
| Mild anxiety | 12 |
| Moderate-to-severe anxiety | 8 |
The average years' spent full-time as a paramedic among the 78 respondents was 9.05 years, with the average length of employment at their current service being 6.51 years. The average age of participants was 33.67 years. Forty-seven of the survey participants were male and 31 female. Seventy-two were white, one American Indian, one African American, one Hispanic or Latino and three ‘other’. Forty-two (53.8%) participants worked in at least one additional job. Twenty-one were single, 46 were married, and 11 were divorced. Regarding education, 28 reported their highest level of education completed was high school, 35 had received an associate's degree and 14 had a bachelor's degree and one had a master's degree.
Participants who worked 12-hour shifts responded to an average of 5.91 calls per shift, with a median call volume of 6. Those on 12-hour shifts got 6.06 hours of sleep on average before their shift, with a median of 6 hours. Respondents who worked 24-hour shifts responded to an average of 11 calls per shift with a median call volume of 12. They had an average of 7.05 hours of sleep before their shift, with a median of 7 hours.
Eight out of 78 (10.3%) participants had moderate to severe anxiety identified by the Beck Anxiety Inventory.
Age had a significant influence on whether a participant experienced moderate-to-severe anxiety (P=0.028; OR 0.594). As age increases, the likelihood of experiencing moderate-to-severe anxiety decreases significantly. Additionally, those who worked 24-hour shifts were significantly more likely to experience moderate-to-severe anxiety than those working 12-hour shifts (P=0.042; OR=0.002) (Table 2).
| Data point | P | Odds ratio |
|---|---|---|
| Length of current employment | 0.676 | 1.211 |
| Years full time | 0.685 | 0.866 |
| Additional jobs: yes:no | 0.688 | 0.594 |
| Age | 0.028 | 0.594 |
| Sex—male:female | 0.381 | 0.305 |
| Marital status—married:single | 0.561 | 0.381 |
| Marital status—divorced:single | 0.515 | 6.997 |
| Number of children | 0.017 | 6.53 |
| Shift—12 hour:24 hour | 0.042 | 0.002 |
| Race: American Indian:white | 0.999 | 0 |
| Race: Asian:white | 1 | 0 |
| Race: African American:white | 1 | 0 |
| Race: Hispanic or Latino:white | 1 | 0 |
| Race: not available or other:white | 1 | 648 834 155 |
| Associate's degree:high-school diploma | 0.03 | 88.15 |
| Bachelor's degree:high-school diploma | 0.999 | 0 |
| Master's degree:high-school diploma | 1 | 0 |
| Number of calls | 0.134 | 0.58 |
| Hours of sleep before shift | 0.521 | 0.62 |
Limitations
Because of the taboo nature of mental health in the EMS profession, it was difficult to find services that agreed to participate in this research. This study received no outside funding, which limited the number of Beck Anxiety Inventory surveys that could be purchased. These two factors resulted in a small sample size.
This study was also limited because participants self-reported anxiety using the Beck Anxiety Inventory. This relied on respondents providing truthful answers. Some may not have accurately reported their anxiety because of denial of anxiety or feared being judged for feeling it.
Discussion
Paramedics who work 24-hour shifts are significantly more likely to experience moderate-to-severe anxiety than those working 12-hour shifts. This could potentially influence the provision of acute medical care and treatment in the prehospital setting.
As age rises, the likelihood of experiencing moderate-to-severe anxiety falls significantly. In addition, as the number of children increases, so does the likelihood of experiencing moderate to severe anxiety.
Those who have an associate's degree compared to those who just have a high-school diploma were significantly more likely to experience moderate-to-severe anxiety. No other educational difference reached statistical significance.
Years of experience, number of calls per shift and hours of sleep before the shift failed to reach statistical significance in the probability of experiencing moderate-to-severe anxiety.
Conclusion
This study found that paramedics who worked 24-hour shifts were significantly more likely to experience moderate to severe anxiety than those working 12-hour shifts. EMS agency administrators are therefore encouraged to re-evaluate the use of 24-hour shifts.
Age also influences the likelihood of paramedics of experiencing moderate to severe anxiety, which becomes less common as practitioners get older.
Additional research is needed to determine if the likelihood of experiencing moderate to severe anxiety when working differing lengths of shifts would remain the same in a larger sample size.
Finally, if these not already in place, strategies should be developed to assist paramedics and other prehospital care practitioners to address anxiety and other mental health disorders.