It is estimated that the average member of the public within the UK will experience one or maybe two traumatic situations in a lifetime—whether that be through witnessing or being involved in an accident, natural disaster, collision, medical episode or traumatic event. Those working in frontline emergency ambulance services however are exposed to distressing and traumatic events on a much more frequent basis (Halpern et al, 2012).
Given the nature of our work, the paucity of evidence in exploring occupational traumatic distress is perhaps surprisingly limited, with the majority of research studies drawing upon quantitative methods to determine pathological impact. Of course, this work is important, and research has informed us that experiencing psychological distress is not just associated with the more significant incidents such as a transport collision or a multi-casualty scene.
Rather, we now know that it's not so much the type of incident which may result in traumatic distress, but rather our perception and interpretation of an event, and what the incident meant for us personally, both emotionally and psychologically. Thus, any aspect of our work can resonate with us, whether from the fear of, or actually, being assaulted; from witnessing a loss of life; the difficulty of wanting to do more for a patient but not having access to the right resources or time; or even from witnessing social situations such as neglect, poor care and loneliness (Regehr et al, 2002).
Traumatic distress may be experienced as having intrusive memories of the incident, perhaps isolating oneself, cutting off friends and family, having difficulty sleeping and/or regulating emotions (NHS, 2018). There are many different ways in which mental and physical wellbeing may be affected.
Regehr et al (2002) highlighted that 82% of the paramedics they observed within their longitudinal 12-year study into traumatic incident exposure, felt overwhelmed or deeply disturbed by an emergency call they had attended. Of these, it was reported that 25% fell into the high range for post-traumatic stress (PTS) symptoms. Of all the studies undertaken into paramedic populations at that time, this research reported one of the highest levels of staff self-reporting PTS symptoms.
More recently, a systematic review and meta-analysis of relevant published literature dating between 1988 and 2016 was carried out by Petrie et al (2018). Their aim was to determine the prevalence rates of post-traumatic stress disorder (PTSD) and other mental health conditions among ambulance personnel worldwide. Twenty-seven articles were included in the review, which covered an overall sample size of 30 878 frontline ambulance workers from across 15 countries. Following analysis of the data, they found that PTSD was the most commonly reported mental health outcome, with a prevalence rate of 11%—that's just over one in ten ambulance staff reporting symptoms of post-traumatic distress.
Other mental health conditions such as anxiety and depression appeared to affect 15% of participants, with general psychological distress affecting 27%. The figures are stark when compared with the global population, of whom 3.7–5.1% are said to have experienced PTSD (Baker, 2018); 4.4% experience depression; and 3.6% experience anxiety (World Health Organization (WHO), 2017). However, Petrie et al (2018) did note from their meta-analysis of data that prevalence rates for PTSD among ambulance employees has fallen within the last few years. This outcome may have resulted from differing reporting tools used within the various studies, under-reporting of PTSD possibly owing to stigma or fear of organisational consequences, or perhaps it is actually representative of a real change in the numbers of individuals affected by this trauma response. The authors speculated that this result may in part be caused by an increased awareness of mental ill-health symptoms, or the implementation of mental health initiatives within some ambulance organisations, such as educational programmes, training and wellbeing checks.
We now know that the impact of not processing the memories associated with traumatic experiences—whether they have just happened, or whether they're long in the past—can lead to long-term psychological distress and somatic responses.
Neuropsychology has advanced our understanding of why and how this occurs, and subsequently helps us to understand how we may begin to protect the mental health of emergency responders who experience distressing events more than others. Most importantly, the brain may be aided by putting things into context and giving meaning to the event so that it can be processed into long-term memory, enabling the person to move on. It's when this can't or doesn't happen that difficulties occur (Li et al, 2017).
One of the most effective ways to process an incident is to talk about it when you feel ready to do so. Talking and providing a narrative of what happened and what you experienced has been found to help normalise post-incident feelings such as sadness about the event, anger, guilt and blame.
‘Hot debriefing’ helps to construct an overview of the incident, a brief timeline, and an opportunity to talk about what went well and what didn't. However, talking less formally with trusted others also helps give context to emotional responses, vent frustrations and talk through worries.
Increasing demand, particularly during winter pressures, makes it ever more challenging to take time to gather our thoughts, or talk with peers or our line manager. However, not having the time to process what's happened, and allow our stress response to reset to a more manageable level before the next call, is not sustainable in the long term. This is when we start to see our colleagues experiencing emotional fatigue, burnout, anxiety, depression or PTSD.
Psychological distress not only affects individuals, but undoubtedly their networks such as their family, friends, colleagues and, on a wider basis, the culture within their organisation and the care that is provided to patients. Rates of absence due to stress in the NHS ambulance service are significantly higher year-on-year than those of other health professional groups, which ultimately impacts upon the health economy (Dodd, 2017). Even more worrying is the increase in suicide rates among ‘blue-light’ staff (Mind, 2016).
In today's climate of increasing pressure upon our emergency medical services, it is imperative that we build welfare into our everyday working activities and cultural practices. The impact of mental ill-health upon individuals has to be taken seriously with protective approaches such as psychological education and self-awareness advice, as well as meaningful supportive processes including opportunity and time out for peer-support and access to counselling.
However, the psychosocial wellbeing of frontline employees—including responding managers and call centre staff—must be viewed as a collaborative process with acknowledgement that responsibility and duty of care lies between organisations and individuals, rather than with employees alone.