Post-traumatic stress disorder among ambulance personnel: a review of the literature

What is PTSD?

PTSD is not a new concept, it has been acknowledged in history dating back to the pre-Christian period. Over the years its recognition and impact on mental health have become increasingly apparent. PTSD was propelled to the forefront of people's minds post world wars, despite various senior military figures and Winston Churchill himself dismissing claims that PTSD existed (Cantor, 2005).

PTSD is described in various ways, but perhaps the most highly regarded source on this mental health issue is the American Psychiatric Association (APA), which states:

Levels of PTSD

The National Institute for Health and Care Excellence (2005) suggests that up to 14% of the general public develop signs of PTSD following a traumatic event. Levels of PTSD within the ambulance service seem to vary and be open to debate, perhaps due to the lack of robust research within this area. A Scottish study of ambulance personnel found that PTSD or related symptoms were present in 30% of the work force (Alexander and Klein, 2001). However, this is 8% higher than a later study in 2004, which suggests that levels of PTSD within the United Kingdom (UK) are around 22% (Bennett et al, 2004). Berger et al (2007) concluded that apparent symptoms indicate 20% of the Brazilian pre-hospital care work force has some degree of PTSD. In contrast, within Western Europe the levels appear to be lower at around 12–13% (Jonsson et al 2003; van der Ploeg et al, 2003). Factors that determine the impact of PTSD on emergency workers may, therefore, depend upon where you are located geographically or possible cultural differences; however, more research in the area is needed to confirm this suggestion.

Measuring/assessment of PTSD

One inherent weakness when comparing these quantitative studies is that the methods used to measure or diagnose PTSD is different. PTSD as depicted by the APA in the publication of Diagnostic and statistical manual for mental disorders (2013: 271–2) has three predominant areas. The first is hyper-arousal, which includes reactions such as irritability or mood swings, out bursts of rage, inflated startle reactions and difficulty sleeping. The second being re-experience, where the individual may recreate the event almost as if re-living the whole experience. Third and finally, avoidance, which can result in a sudden reduction in motivation, isolation and avoidance of associated stimuli, reduced displays of passion towards others, and avoiding all thoughts and feeling associated with initial traumatic event. This section also includes avoidance through substance abuse or use from prescribe medication, alcohol or illicit drugs (APA, 2013: 271–2).

The only assessment tool/criteria that incorporates all of the areas of PTSD in its assessment is the DSM–5 devised by the APA (2013), yet at present all the literature found investigating levels of PTSD among emergency staff fails to use it within its methodology. Authors such as Alexander and Klein (2001), Regehr et al (2002), van der Ploeg et al (2003), Macnab et al (2003) and Bennett (2004) all use the Impact Events Scale (IES) (Horowitz, 1978). The IES is a self-reporting scale used to measure areas of disturbing thoughts such as nightmares/flashbacks, and behavioural change such as avoidance. The results of the scale are given in numerical format, from 0–8 being low traits of symptoms, 9–19 Medium and 20+ high. Hence, reasonable comparisons can be made incorporating only two aspects of PTSD assessment, those being re-experiencing and avoidance. This creates a shortfall in the robust nature of the research and difficulties in taking other studies into account such as Jonsson et al (2003), which uses an adapted Swedish version of the IES scale that as discussed, only incorporated two areas highlighted in PTSD criteria.

Other services and PTSD

In comparison with other emergency services, ambulance personnel have higher instances of PTSD than fire-fighters and police officers combined; this was even if the services attended the same incident (Marmar et al, 2006). Jonsson et al (2004) echoed this point concluding that ambulance workers recorded considerably stronger and more frequent symptoms when compared to other emergency responders. Conversely, a quantitative study in Canada reported that the level of police officers with full or partial signs of PTSD is around 13% (Martin et al, 2009). This result is surprisingly similar to the ambulance service in Western Europe as previously discussed; however, the scale used to generate this result was not included within the study (Slottje et al, 2008).

Switching focus slightly to associations with the military one study highlighted that United Nation (UN) soldiers and ambulance workers within the same country had strikingly similar levels of PTSD when tested (Larsson et al, 2000). This correlation may need closer attention as a later study by Berger et al (2012) implied that a number of ex-military personnel are employees within the ambulance service. Further still, trauma in the pre-hospital care environment is considered to be just as intense as military conflict (Larsson et al, 2000; Rick et al, 2004). This could give an explanation to the similar levels of PTSD between the military personnel and emergency ambulance workers.

Personality traits

While conducting the literature review, it became apparent that there were an array of points highlighting a link between personality traits and those individuals more susceptible to developing PTSD or those more resilient (Southwick et al, 1993; Regehr et al, 2002). Alexander and Klein (2001) argue that the general perception of individuals who work within the emergency ambulance service, have tough or more resilient personalities to deal with trauma, thus do not feel the psychological impact of trauma when compared to the general public. This may be the case as a small qualitative study was conducted on ambulance staff using the Hardness Scale (HS) and the results supported this theory (Maddi and Kobasa, 1984). The HS is used to measure three specific personality traits, which are presumed to show if a person is hardy or resilient to stress; the scale is measured from low hardiness to high hardiness. The three areas include control, commitment and challenge. If the individual feels in control, has significant commitment to the task and understands the task is a challenge as opposed to a threat, then a high hardness score would be achieved. However, more research would be required to give a definitive answer.

One benefit of this resilience is that ambulance staff could be less susceptible to PTSD and associated symptoms. To add weight to this concept, people who don't have an overly emotional reaction to extreme terror, helplessness or life-threatening events, inevitably had fewer instances of PTSD (Declercq et al, 2011). In contrast, the lack of expression or evasion shown by an individual may create a vulnerable personality more susceptible to PTSD, or be classed as avoidance, which is a result of the illness itself (Carducci, 2009). Declercq et al (2011) also recognised that reactions to stress are unique to the individual and based on one's perception of the situation at the time of the event occurring. The resilient or less emotionally responsive personality traits can be summarised as: those who have a strong concept of self-awareness, have influential leadership qualities, develop their own psychological strategies in dealing with stressors, and have an ability to resolve problems (Jonsson et al, 2004; Marmar et al, 2006).

Gender difference

Gender also needs to be taken into consideration within the development of PTSD and its symptoms. In the general population there is a notion that females are increasingly susceptible to developing PTSD when compared to males (Kessler, 2000; Tolin and Foa, 2006). In contradiction to this theory, Jonsson et al (2003) claim that within the ambulance service, levels of PTSD and related symptoms are at equilibrium between genders. However, in some literature males appear to have a tendency to develop symptoms of PTSD, especially those who have been in long-term employment within the pre-hospital care environment (Davidson et al, 2004; Berger et al, 2007).

Interestingly, when comparing levels of PTSD with the police and military, gender played no role, but was simply down to individual responses (Berger et al, 2012). There are a few reasons why females may have lower instances of PTSD when compared to their male colleagues, the first being that the selection procedure for the emergency services is particularly demanding, which may expose candidate's traits of PTSD symptoms during this selection process (Arthur et al, 2001). Secondly, intense training and the nature of the job may only attract hardy or resilient women to this kind of field (Lilly et al, 2009). Finally, women are suggested to have advanced coping mechanisms as they draw on social support more regularly and openly talk about emotional problems than their male counterparts, hence reducing potential to develop PTSD (Bennett et al, 2005).

Impact of long-term employment

There is a predominant theory that length of service or long-term exposure to trauma is inherently linked to PTSD (James, 1988; Alexander and Klein, 2001; Jonsson et al, 2003; Jonsson et al, 2004; Berger et al, 2007). The most recent study echoed the previous works of others and expresses that repeated exposure to trauma can make ambulance personnel susceptible to developing PTSD symptoms, more so than other services (Berger et al, 2012). To further explore PTSD among ambulance staff, quantitative comparisons can be made with police and fire services and the findings indicate that ambulance personnel are significantly at higher risk of developing PTSD (Di Fiorino et al, 2004). The danger is not that ambulance employees develop PTSD, but it has a domino effect on physical and psychological symptoms, compounding and prolonging PTSD reactions (Yehuda and McFarlane, 1995; Marmar et al, 2006). A further recommendation is that there should be equal emphasis on career-long treatment for trauma exposure, not just an immediate reaction to a particular event (McFarlane and Bryant, 2007). When looking at chronic PTSD, other factors must be considered, these include: the severity of the trauma witnessed, previous history in the personal or professional life of the individual, and overall education through schooling, college and university (Ballenger et al, 2000; Davidson et al, 2004). Prolonged illness has strong associations, with other complications such as depression, medication addiction, self-harm, alcoholism, drug abuse and suicide (Royal College of Psychiatrists, 2010; Davidson et al, 2004). On the other hand, a study concluded that PTSD and its development had no relationship with repetitive exposure to distress or trauma (Declercq et al, 2011). A weakness in the current research may be within the methodology used to measure or test for PTSD, as it required individuals to recall an extremely stressful event in the past. This could create a bias or a vague result as individuals may display signs of PTSD which are stronger than they would normally, as they are asked to specifically recall an event of extreme stress, fear or horror. This may provoke PTSD reactions that would not normally be displayed by the person being measured or tested (Brewin et al, 2002; Bledsoe, 2003).

Pre-hospital environment and culture

One unavoidable area which has yet to be discussed around the subject of PTSD is the organisation itself that ambulance personnel work for. Interestingly, a qualitative study of front line ambulance staff concluded that a common consensus was that management never displayed concern for employee wellbeing (Alexander and Klein, 2001). To add weight to this point, management are also perceived to be insensitive and possibly ignorant to the situation, as discussed by Alexander and Klein (2001) and Smith and Roberts (2003). Extending this point further, in 1993 the US Supreme Court found an ambulance service neglectful towards it employees, ruling that there was an inherent lack of awareness of current evidence available surrounding PTSD; therefore, putting front line ambulance staff at great risk of developing PTSD (McFarlane and Bryant, 2007). This may be an extreme case; however, it highlights the stress caused by organisational issues rather than operational trauma, which is entwined within emergency services (Brough, 2004). This research suggests that an obligation of the organisation is to identify those who are susceptible to PTSD, or display symptoms; however, it may be somewhat unfair to place the whole burden of a personal illness and diagnosis on the ambulance service itself (Smith and Roberts, 2003; McFarlane and Bryant, 2007).

Personality testing

Pre-employment personality testing will enable the more tolerant and hardy individuals to be identified and protect the more vulnerable from potential psychiatric harm (Maddi and Kobasa, 1984). This creates a positive reason to implement the HS or similar method such as the General Health Questionnaire (GHQ) (Goldberg and Hillier, 1979; Bartone et al, 1989). The testing will enable these individuals to be monitored closely if employed and give the organisation the opportunities to provide the correct support and monitor improvement (McFarlane and Bryant, 2007). The ruthlessness of the process, however, may prevent those who would be mentally equipped in dealing with trauma exposure from being employed in the ambulance service (Ursano et al, 1999). The benefits of filtering may reduce the impact of mental health issues within the work place, employing the more suitable candidate to deal with stress, boosting morale, reducing sickness and increasing productivity as a result (Regehr, 2001; Hough and Oswald, 2008). There are many debates around this intricate subject which touch on the appropriateness, accuracy, ethical and legal implications of personality testing (Carducci, 2009). However, the ambulance service is inherently associated to trauma on a day-to-day basis, and this is a clear reason to ensure that those vulnerable are not placed in the high-risk occupation, as it could be seen as negligent (McFarlane and Bryant, 2007). More research is needed on the topic to create definitive answers and strategies need to be further explored.

Job rotation

With the evidence weighted heavily linking long-term service and chronic exposure to the development of PTSD and the dangers of further progression to a chronic condition, job rotation is a vital tool in reducing this impact (Herman, 1992; Jonsson et al, 2003). The proposal is to implement a system whereby front line workers have two weeks off duty every second month (Ho et al, 2009). A problem to this approach would be the staffing levels required in the ambulance service would have to increase by approximately 25% (Heaney et al, 1995). This will create financial challenges for the ambulance service (Smith and Roberts, 2003). However, the costs may be offset as effective job rotation reduces stress and enhances staff commitment to the organisation (Ho et al, 2009). In turn, this effectively reduces turnover and absenteeism due to stress, therefore reducing overall costs involved in training, hence counterbalancing the cost implied with off duty job formulation (Burnes, 2009; Senior and Swailes, 2010). Ho et al (2009) makes a direct link between effective implementation of job rotation and reduction in mental health issues among medical personnel. Job rotation may be the only way to ensure staff get appropriate and regular time away from trauma and allow themselves to return to relative normality and reduce or prevent PTSD symptoms, thus creating better health among employees (McFarlane and Bryant, 2007). In turn this will reduce sickness, boost morale and create a more proactive workforce, providing that ambulance work is the stress trigger and not from an external source (Heaney et al, 1995).

Debriefing

The Cochrane collaboration conducted a review into single session debriefing following a traumatic event and the likelihood of preventing PTSD. It concluded that there was no evidence to support single session debriefing and the strong suggestion that compulsory procedure should terminate (Rose et al, 2002). This is due to the fact that single session debriefing could deeper embed the event in an individual's memory and with no follow up it is seen as a slightly pointless as debriefing takes time, with symptoms developing weeks or months after an event. However, the study was in the normal population and not with specific focus on the ambulance service, therefore debriefing following a traumatic event is still suggested with scheduled follow up session's one month later (Mitchell and Dyregrov, 1993; Rick and Briner, 2004; NICE, 2005). The negative associations with debriefing creates caution around mandatory implementation due to the fact that the methodology involved can cause restrictions associated with PTSD and treatment (Rose et al, 2002; and Hourani, et al. 2011).

A limitation of debriefing may be due to the ambulance staff perceptions of it being used as a management tool, rather than a treatment method, thus creating resistance to treatment (Rick and Briner, 2004). There are stigmatic associations to counselling as emergency workers are presumed to be courageous and hardy, and are therefore almost expected to be able to cope with the work without any personal toll (James, 1988; Alma and Wright, 1991). This stigma or individual attitude could potentially be reduced by the organisation implementing counselling as part of the organisational structure and the individuals being proactive in participation (Alma and Wright 1991; Bennett et al, 2005). With more structured treatment and preventative measures in place, it could change perceptions of treatment being used as a management tool, to proactive individualised support for staff wellbeing and compassionate managerial approach (Boscarino et al, 2006). There are differing reasons to implement a debriefing process, one suggestion is that many ambulance workers are unable or unequipped to realise that they are suffering from PTSD, and debriefing could enable staff and management to be educated on the risk and benefits of treatments/preventions of PTSD and the illness itself (Kessler, 2000). The benefits of this process would be better understanding of PTSD among staff (including management), greater outlets of communication for employees to help and support each other, access to current information resources for PTSD, reducing absence, and increasing motivation (Rosenfeld et al, 1997; Chang et al, 2005). However, more research needs to be undertaken to fully understand the impacts of the debriefing process which are applicable to ambulance personnel and the associated benefits.

Social support

The tribe-like nature of employee inter-relationships is a strength that can be built upon by increased social networks (van der Ploeg et al, 2003). This can be achieved through various methods such as: online forums, increased social interaction through family events, and team building days (Jonsson et al, 2004). In turn, this could help to reduce PTSD with the assistance and understanding of family, colleagues and management as recommended (NICE, 2005). The idea of management being involved in the process through regular meetings may create a positive platform to ensure employee welfare is acknowledged and taken seriously (McFarlane and Bryant, 2007). One downfall to management being involved with the process is that employees may see it as a symbolic gesture to ensure they have fulfilled the new change (Rick and Briner, 2004). Bennett et al (2005) also expressed concern about the impacts of organisational stress, and how it has a detrimental impact on the health of workers, possibly more so than front line ambulance duties.

Overall, the concept of PTSD is focused on feelings and behaviours, so people will have varied and individual reactions (Horowitz, 1983; Stein, 2002). Therefore, it is difficult to highlight these individuals who may need treatment and indeed they may refuse it entirely. The individual's health may indeed be hindered if they are not willing to accept help or indeed not interact within a supportive social network (Sayer et al; 2009Precin, 2011).