Fit to practise: does more need to be done to improve the health and wellbeing of paramedics?

The body

The physically strenuous nature of a paramedic's job calls for high levels of physical fitness in order to maintain their ability to work, and to stay healthy. Sterud et al (2006) conducted a worldwide meta-analysis, reviewing 49 studies to assess the health status of ambulance personnel, where mental health disorders, musculoskeletal injuries and cardiovascular disease had a high prevalence in the studied populations. Due to the varying scope of practice between ambulance services, forming generalisations pertaining to all UK paramedics with regards to prevalence rates is difficult (Sterud et al, 2006). However, recurrent themes suggest paramedics are at greater risk of injury or illness compared with the general population.

There is also a correlation between age and injury which has an effect on early retirement, and work days lost due to sickness and injury (Sterud et al, 2006; Arial et al, 2014). These create a financial strain on ambulance service providers. The reasons for injury are attributed to difficult working environments that promote poor lifting techniques (Arial et al, 2014). Where lifting aids are available, they have been shown to reduce the risk of injury; however, due to the difficult working environments encountered, they are not always practical to use (Arial et al, 2014).

Emphasis has been placed on looking at the problem of manual handling and developing lifting tools and techniques to minimise the risk of injury (Hignett, 2015), but paramedics still adapt their environment to their advantage to reduce the risk of injury, suggesting that these lifting aids are not sufficient. Arial et al (2014) observed paramedics undertaking heavy lifts down a flight of stairs, leaning against a wall as a means of support, and cited it as one such example of using the environment to aid handling. The authors did not discuss the strength and physical capabilities of their participants and it is unclear as to what the health of the participants was, beyond self-reported history of back pain in 47.8% of the participants. A fundamental principle in strength and conditioning training is that if the object/patient is of a weight that will stress the individual beyond their limits, the risk of injury increases (Bompa and Buzzichello, 2015). Arguably, if paramedics are given the right tools to perform a lift, but still require support (i.e. from a wall), their presumed lack of strength is putting them and the patient at risk of injury.

Back strength and hip flexibility are linked closely to the incidence of back injury. Crill and Hostler (2005) assessed the back strength and hip flexibility of a convenience sample of North American ambulance personnel. Male participants stated (through self-reporting tools) that their back strength was sufficient. Back strength was tested by lying prone, holding their upper body up via the hips. Holding this position for a minute was deemed normal. Flexibility was measured by lying supine and a leg lifted up via the hip until the participant reported it as becoming uncomfortable, or the anterior superior iliac spine began to move (80°–90° is normal). These tools are used by physiotherapists to assess their patients when prescribing treatment; however, the validity of this methodology was a noted weakness of the study (Crill and Hostler, 2005). Majority of participants were seen to have a Body Mass Index (BMI) classed as obese, and were medicated for at least one health complaint with 36% having a history of work-related back injury in the last six months. Exercise participation was reported being low or non-existent. Despite perceptions of adequate back strength, participants overestimated their strength, averaging 37 seconds in the back strength test. The authors noted there was no difference in hip flexibility and back strength between those with a history of back pain and those without. Poor strength of the muscles supporting the lumbar spine has been linked to lumbar injury, disc herniation and joint mobility issues (Mok et al, 2004). Crill and Hostler (2005) recommended strength and conditioning training to improve back strength and hip flexibility to reduce the risk of injury.

How fit is the paramedic population?

Data surrounding the physical fitness of ambulance staff is limited. Based on their findings, Gamble et al (1991) recommended physical fitness regimes be introduced to ambulance personnel, concluded from their study of 230 Belfast ambulance service personnel. Using a battery of fitness and strength tests, cardiovascular fitness was deemed to be the same as the normal population, although more than half of the participants were overweight. When performing a simulated stretcher carrying exercise, participants were showing high levels of exertion and exhaustion. This work by Gamble et al (1991) was the first piece of research to use work-related exercise tests to demonstrate the physiological demands placed on frontline staff, highlighting that over half the staff tested were struggling to meet the physical demands of the job.

Gamble et al (1993) demonstrated that when ambulance staff exercised three times a week, the ability to perform tasks, such as stretcher bearing improved when compared with a non-exercising control group. A 10-week exercise programme was implemented, playing football twice a week to improve cardiovascular fitness and circuit training once a week to improve muscular strength. The rationale for using circuit training was to complement the muscle groups and mechanical movements most commonly used. The rationale for the use of football as a form of exercise was not explained; whether a more effective training regime could be utilised remains unclear.

In support for the rationale of regular exercise, Aasa et al (2008) showed that a one-year exercise programme involving 19 personnel from the Swedish ambulance service reduced fatigue in simulated carrying exercises. Three sessions per week were prescribed to the exercise group, comprising two strength and conditioning workouts, and an aerobic exercise session. Researchers controlled the intensity of these workouts by ensuring the participants were working at a percentage of their maximum heart rate. A control group was used, where participants continued their normal routine, which may or may not have included exercise.

A key difference appears between the two studies: Aasa et al (2008) places greater emphasis on strength and conditioning exercise compared with Gamble et al (1993). Aasa et al (2008) believed that a programme improving trunk and leg strength, and reducing the associated health risks linked to lifting patients and carrying stretchers, would be of greater benefit, though they noted no significant difference between the training group and the control group. The majority of the control group participated in some form of exercise. It should be noted that there was an issue of compliance in the exercise group: two groups emerged within it. One of these groups exercised three or more times a week and the other would exercise less than twice a week. The authors compared these two groups and found in the same simulated carrying task, that the group that exercised three or more times a week had greater cardiovascular fitness and lower blood lactate accumulation than the group that exercised twice or less often per week. This is a significant finding which supports conclusions drawn by Gamble et al (1993), but further investigation is required to determine which exercise regime is most appropriate.

The effectiveness of exercise has only been measured with small samples in controlled situations; for example, carrying a simulated patient down a flight of stairs (Gamble et al, 1993; Aasa et al, 2008). This area requires further exploration. Measuring a paramedic's ability to perform a carrying exercise is not indicative of the ability to manage the demands of their job, as heavy lifting is only one risk factor associated with this line of work (Sterud et al, 2008; Betleham et al, 2014). Injury prevention and reduction in sick leave was not investigated in these studies, and the full benefit of regular exercise and the type of exercise regime that should be implemented remains unclear.

The mind

The psychological wellbeing of a paramedic is governed by a balance between job satisfaction and the stresses placed on them to do their job (Alexander and Klein, 2001; Wiitavaara et al, 2007). These include, but are not limited to, the following: exposure to challenging and traumatic situations, operational demands and workload, long and unsocial shifts, inconsistent sleep patterns, and personal life stressors (family and financial commitments) (Sterud et al, 2006; Hegg-Deloye et al, 2014).

Depression, anxiety and post traumatic stress disorder (PTSD) are the most common mental health issues affecting paramedics (Hegg-Deloye et al, 2014). Incidence of PTSD is approximately four times higher in emergency worker populations versus the general population (Sterud et al, 2006). This, in turn, is believed to increase the risk of cardiovascular disease, consequently increasing the incidence of sick leave. Within a cross-sectional Danish sample, Pek et al (2015) noted that there was no significant difference between the mental health of paramedics and the general population. Despite a higher level of exposure to stressful situations, job satisfaction mediated the damaging effects those situations can have, supporting the notion that a balance between job satisfaction and work stresses is paramount (Alexander and Klein, 2001; Wiitavaara et al, 2007).

Pek, et al (2015) note the association between poor mental and physical health in Hungarian ambulance staff, a finding that had previously been noted in a cohort of Danish ambulance personnel (Hansen et al, 2012), and in the wider literature on mental health disorders and physical health in the general population (Ströhle, 2009; Rosenbaum et al, 2015). Those suffering from anxiety, depression and stress are more likely to be leading a sedentary lifestyle and are at great risk of cardiovascular disease, hypertension and diabetes.

Gayton and Lovell (2012) noted that Australian paramedics who had a greater resilience to these work stresses were in better physical condition. Resilience, which takes about five years to develop, is built by the individual, and is dependent on exposure to job stressors (Gayton and Lovell, 2012). At this point the job no longer appears to have the same emotional impact: those with greater resilience appear to have fewer health complications. However, this cross-sectional study did not demonstrate cause and effect. Newly qualified paramedics were less resilient than their more experienced colleagues, but, it was difficult to determine what qualities a newly qualified paramedic should have in order to limit the psychological damage done by the job.

Beyond resilience to the job, various coping mechanisms have been examined to prevent or treat the psychological impact of ambulance work. Peer and managerial support are considered positive ways to reduce the risk of mental health problems (Donally and Siebert, 2009), although this is not always available when demand is high. There is some evidence that individuals may have a preference as to the time of day they would prefer to work, some preferring an early start (Sofianopoulos et al, 2012). Control over the scheduling of shifts and allowing staff to choose when they work may reduce home-life stress (Hansen et al, 2012). From an operational point of view, self-rostering is difficult to achieve and can leave an ambulance service vulnerable to not meeting demand.

However, staff continue to adopt unhealthy behaviours. The reviews of the Hungarian ambulance personnel and Greek ambulance staff (Moustou et al, 2010; Betleham et al, 2014), demonstrated that to cope with the stress encountered, staff rely on unhealthy behaviours, such as excessive alcohol consumption and eating unhealthy foods. Interestingly, Betleham et al (2014) found that participants admitted their health status was poor, but believed their fitness was average, despite performing little to no exercise. From the sample, those who did regular exercise reported lower levels of stress and a better health status. The type of exercise was not explored, therefore it is hard to extrapolate and advise as to what type of exercise is beneficial for ambulance staff. Furthermore, the participants had to rate their fitness as either ‘Excellent’, ‘Good’, ‘Fair’ or ‘Poor’, which, in terms of physiological parameters, means very little. This lack of definition can be misleading. Hegg-Deloye et al (2014) noted that relying on unhealthy behaviours is more likely to cause mental health problems.

Exercise as a treatment for mental health disorders

In the general population, there is a link between mental health problems and a lack of exercise (Rosenbaum et al, 2015; Ströhle, 2009). Improving the physical fitness of paramedics could have benefits beyond the physical demands of the job, as previously demonstrated in the studies discussed above. However, Paterson et al (2014) found that Australian paramedics did not have enough time to exercise and perhaps the lack of opportunity to exercise may need to be addressed. Ultimately, the evidence surrounding regular exercise and the benefits to a paramedic's psychological health is limited.

Gerber et al (2013) showed that within the general population, people were less likely to suffer stress related mental health problems if cardiovascular fitness was high. Participants came from various socioeconomic groups within Sweden. All participants were screened and only healthy individuals not on regular medication were included. The cause of stress within this sample was not mentioned and may not be job specific. It is difficult to say whether job-related stress could be treated by exercise given the uncontrolled variables in this study. With a cohort that has no health complaints, it is difficult to extrapolate this data to ambulance staff who have reported having chronic health complaints (Hegg-Deloye et al, 2014; Pek et al, 2015).

Exercise interventions as treatment for mental health problems have gained popularity in recent years, demonstrating protective properties against stress and anxiety (Asmundson et al, 2013). Regular exercise reduces hormonal response to short and long term stressors, improving the body's ability to deal with situations that would have otherwise caused the stress to thrive in the individual (Ströhle, 2009; Asmundson et al, 2013).

Definitive exercise programmes to treat mental health conditions are still being debated (Cooney et al, 2012). The research is hindered by a lack of randomised controlled trials, small sample size and poor compliance rates. Even the intensity of the exercise programmes has been difficult to evaluate (Asmundson et al, 2013).

A review by Asmundson et al (2013) noted that programmes exceeding nine weeks, with exercise sessions lasting more than 30 minutes three times a week, have shown the most promising results. Compliance is best when exercise intensities start low, with appropriate support in a gym with a qualified instructor in both physical fitness and mental health disorders. Walking-based exercises are amongst the most popular, due to their low cost and ease of access. No difference has been seen comparing walking with running, circuit training or weight lifting-based exercise. However, inconsistent results throughout the literature make it difficult to generalise data (Asmundson et al, 2013).

Ströhle (2009) noted that when emphasis is placed on having fun with realistic goal setting, the participants' fitness is more likely to improve, their self-worth increases and exercise intensity can increase in a step-wise fashion, ensuring further psychological and physiological benefits. These sessions are typically gym based, which are costly, as equipment and personnel are required, and cohort adherence is difficult if the facilities are not local to the participants. Home-based interventions are a cheaper alternative, and have been shown to be popular with self-reporting exercise diaries used to monitor progress. However, without regular contact and motivational support, the participant is likely to lose interest in the programme.

Studies have focused on treating mental health disorders in the clinical and non-clinical population. To date, no research has investigated the effects of exercise on treating the mental health of ambulance staff. Exercise appears to play a vital role in reducing stress, depression, and consequently, a ‘burnout’ (Gerber et al, 2013). Working conditions and operational demands appear to cause more stress than the incidents paramedics attend (Hegg-Deloye et al, 2014; Pek et al, 2015). Where staff have been allowed to self-roster, and are given appropriate support, rest and recovery from demanding situations (Sofianopoulos et al, 2012), incidents of mental health problems were reduced. However, this is not always feasible. Paramedics have reported they do not get enough time to exercise (Paterson et al, 2014), and risk factors such as cardiovascular disease, hypertension and diabetes are prevalent in staff who do not participate in regular exercise even in the absence of mental health issues (Hegg-Deloye et al, 2014). Therefore, further research needs to be conducted into the feasibility and effect of regular exercise on the wellbeing of paramedics and front line ambulance staff.

Who is responsible?

The Health Professions Council is clear that it is down to the individual registrant to be fit to practise (Health Professions Council, 2007). Employers, at their discretion, utilise pre-employment fitness testing, but the evidence for their validity and reliability is limited. An Australian study found that ambulance services were hiring staff irrespective of whether they had scored low on aspects of the physical fitness test (Thornton and Sayers, 2014). This was attributed to the scoring system used to assess the subjects. Despite scoring low or failing in several areas, they were compensated for by high scores in other areas of the test. Raising the standard in pre-employment selection could improve the overall health status of the workforce. It has been noted that those who go into employment predisposed to a back problem or low fitness levels are more likely to suffer work-related illness or injury (Thornton and Sayers, 2014).

One possible area where responsibility for paramedic health and wellbeing in the UK could be directed is at the academic institutions that are educating the paramedics of the future. Paramedics are required to attain higher education qualifications increasing the standard of pre-hospital care available to the UK public (Williams, 2012).

A pilot study of Australian student paramedics demonstrated that students are at risk of emotional distress from the incidents they attend (Sheen et al, 2012). Students and newly qualified paramedics, who face the same demands as their experienced peers, have a lack of resilience to the stresses placed upon them, according to Gayton and Lovell (2012). Resilience training in the Australian education system accounts for four hours of lecture time (Gayton and Lovell, 2012). Studies exploring mental health in young adults have demonstrated a link between better physical health and a reduced likelihood of mental health problems (Cooney et al, 2013). Arguably, the student paramedic population is at a greater risk of mental health problems than their peers in the general population. Ensuring students are physically fit to not only cope with the physical demands of the job, but also the psychological demands, is an area that requires further research (Sheen et al, 2012).

This puts an interesting spotlight on higher education institutes in the UK, as responsibility is being placed on them to provide future paramedics the appropriate body of skills and knowledge. Arguably, physical fitness has a vital role to play in a paramedic being able to fulfil their role. Therefore, should academic institutes provide a physical education programme as part of their curriculum to ensure the ambulance service is employing staff who are not only academically highly trained, but also physically healthier?

Conclusion

Compared with the general population, paramedics are at greater risk of work-related physical injury and mental health problems (Sterud et al, 2006; Betleham et al, 2014; Hegg-Deloye et al, 2014). Regular exercise has been shown to improve the fitness of paramedics and allow them to better perform and handle physical tasks (Gamble et al, 1993; Aasa et al, 2008). However, it remains unclear whether this will also reduce work-related sickness and injury. The impact exercise has on coping with the psychological stressors of ambulance work is yet to be properly investigated. Literature surrounding exercise as a treatment for mental health disorders has shown promise (Ströhle, 2009; Asmundson et al, 2013); however, throughout the literature, methodological challenges hinder any definitive conclusions. Research should focus on what impact regular exercise has on the health and wellbeing of paramedics, and consider if stringent pre-employment testing and education of student paramedics in personal health and wellbeing could reduce work-related illness and injury. Ultimately, a healthy work force will ensure patient care is not compromised.

Key Points