Mental Health Issues Of Paramedics
Paramedics are often faced with unique challenges as part of their role, given the unpredictable nature of the job. They have to utilise critical thinking skills and perform varying tasks on-demand in highly stressful environments (Williams, Onsman & Brown, 2010). Tasks frequently require precise management of medications alongside clinical skills, negotiation of varying social and medical issues, all whilst operating in complex and challenging clinical environments (Sofianopoulos, Williams & Archer, 2012). With long hours and an ever-increasing workload, paramedics are continually challenged by the physical and psychological demands of the job (Sofianopoulos, Williams & Archer, 2012). Paramedics are also often witnessing to traumatic events and may be subject to inappropriate and abusive language fuelled by drugs or alcohol which is an additional external stressor when on the job (The Senate Inquiry into Mental Health, 2018). Traumatic events may lead to the development of psychological distress, poor morale, and low self-esteem which are all linked to an increased risk for developing post-traumatic stress disorder (Misra, Grrenberg, Hutchinson, Brain & Glozier, 2009). Paramedics who experience job-related stressors and exposures are at an increased risk of mental health morbidity (Stanley, Hom & Joiner, 2016). The Senate Inquiry into Mental Health (2018) affirms that paramedics are likely to experience some form of physical or psychological harm during their careers. This may manifest itself in various ways including stress, anxiety, fatigue, post-traumatic stress disorder, and even suicide (The Senate Inquiry into Mental Health, 2018). This essay will discuss in detail the organisational and psychosocial challenges that may affect paramedics’ mental health, in particular, stress, fatigue, and post-traumatic stress disorder. The impacts this has on paramedics, the Ambulance service, and the community as a whole as well as recommendations for change will also be considered.
The paramedic role requires an exceptional set of skills with unique abilities to respond to various medical emergencies, motor vehicle accidents, suicides, acts of family violence, and child abuse just to name a few (Jones, 2017). Paramedics are required to perform varying tasks and practice advanced clinical interventions using sophisticated treatments and technology to patients who are often facing a health crisis (Sofianopoulos, Williams & Archer, 2012). Paramedics are vital to the community and fulfil a complex role that requires them to perform challenging tasks in unregulated environments with limited support (Gough, 2018). They are required to make critical clinical decisions under pressure that may have significant consequences on people’s lives (Sofianopoulos, Williams & Archer, 2012). Paramedics work all hours of the day and night, through harsh weather conditions and often in situations of high physical risk (The Senate Inquiry into Mental Health, 2018). These tasks are frequently highly stressful; coupled with an ever-increasing workload, the physical and psychological demands on paramedics is a constant challenge (Sofianopoulos, Williams & Archer, 2012).
Paramedics may be subject to significant external stressors including abusive language and physical assault (The Senate Inquiry into Mental Health, 2018). Given the nature of the role and the exposure to significant traumatic events, the risk of developing psychological harm is substantial (Jones, 2017). Further, since paramedics are required to work long hours requiring sustained attention, there is an increased risk of medical errors and poor judgement attributed to fatigue (Sofianopoulos, Williams & Archer, 2012). Therefore, fatigue suffered by paramedics poses a significant threat to personal and public safety (Sofianopoulos, Williams & Archer, 2012).
Fatigue is a common condition experienced by paramedics. Shifts necessarily span twenty-four hours, thus paramedics are required to work day and night, often with only short rest periods between shifts (Sofianopoulos, Williams & Archer, 2012). Night shifts are especially problematic due to the circadian adjustment and are associated with increased fatigue and involuntary sleep at work (Courtney, Francis & Paxton, 2013). Most paramedics work 10-hour day shifts and 14-hour night shifts, a rostering structure that been in operation for the last 30 years (Courtney, Francis & Paxton, 2013). Drawing on reviewed literature, this shift work pattern could arguably pose significant health risks to paramedics (Courtney, Francis & Paxton, 2013); it is vital paramedics have satisfactory recovery time to execute tasks with confidence and precision to ensure personal safety as well as patient safety (Pyper & Paterson, 2016).
Sleep disturbances and fatigue have considerable impacts and hold the potential to compromise the role of the paramedic (Sofianopoulos, Williams & Archer, 2012). It is well documented that fatigue can significantly negatively impact on concentration, judgement and mood with potential further negative effects on decision making, problem-solving and memory impairment leading to decreased work productivity and performance (Pyper & Paterson, 2016). Drug administration, critical decisions, high-speed driving, and communication are routine in often highly stressful environments and may also be negatively affected due to paramedic fatigue (Sofianopoulos, Williams & Archer, 2012). Sleep disturbances can lead to poor quality of life, cognitive impairments, and mood disturbances and also pose a risk of developing mental health and substance abuse disorders (Jones, 2017). Stress disorders have been reported by Jones (2017) to be significantly associated with sleep disorders in paramedics, while the risk of suicide and alcohol use is borderline significantly associated.
Stress is a manifestation of body reactions to a particular change of environmental and emotional factors causing a shift in the autonomic nervous system (Sarnowska et al, 2018). Depending on its nature, stress can carry significant negative consequences and can cause severe weakening of the human body (Sarnowska et al, 2018). Consequences include impairment of ability to make critical decisions, impaired judgement, lack of concentration and distraction (Sarnowska et al, 2018). Paramedics are required to draw on these skills every shift to ensure safety of the community as well as maintain personal safety. Occupational stress may be defined as “physical and emotional responses occurring when the requirements of the job overload the worker’s adaption” (Hegg-Deloye et al, 2014, pg 242). Working for the ambulance service involves working on the frontline in often chaotic and unpredictable environments while making critical decisions (Sterud, Hem & Ekeberg, 2008), placing considerable stress on paramedics (Mildenhall, 2012). However, it is not only the psychosocial stressors experienced by workers; paramedics experience everyday work burdens characterised by organisational challenges that represent stressors associated with the job (Hegg-Deloye et al, 2014).
Organisational challenges experienced by paramedics include workload, varying shifts including night and day, long hours, unforeseen overtime, and an increasing demand to achieve management targets (Hegg-Deloye et al, 2014). Periods of stress can be associated with an increase in cortisol, the body’s main stress hormone, and catecholamine levels as well as cardiorespiratory reactions (Hegg-Deloye et al, 2014). Prolonged exposure to these levels can lead to negative psychological and physical outcomes affecting mood and emotions (LeBlanc et al, 2011). Accumulating evidence suggests stress responses are associated with decreased clinical performance resulting in reduced public safety (LeBlanc et al, 2011). Post-traumatic stress disorder is a severe consequence of severe stress and may develop after a significant traumatic experience or an accumulation of events (Sarnowska et al, 2018).
Post-traumatic stress disorder (PTSD) is characterised as an anxiety disorder experienced by an individual after exposure to a traumatic event or repeated shocking events (Hegg-Deloye et al, 2014). It is labelled as one of the most severe emotional disorders that have significant consequences on mental and emotional health (Sarnowska et al, 2018). PTSD is extreme aftermath of severe stress (Hegg-Deloye et al, 2014). Feelings of shame, weakness, and mental defeat with indirect associations of negative feelings and emotions of family members are common amongst sufferers (Sarnowska et al, 2018). Repeated exposure to stressful events can lead to psychological exhaustion with each new event a further risk factor for developing PTSD (Hegg-Deloye et al, 2014). It may not be a specific event that results in traumatic stress, but rather our perception and interpretation of the event (Mildenhall, 2012). Therefore, any aspect of the job may resonate with an individual with varying emotional and psychological reactions and emotions (Mildenhall, 2012).
Paramedics have been found to have higher levels of PTSD compared with the general population likely due to the increased risk of exposure to traumatic events (The Senate Inquiry into Mental Health, 2018). The stigma associated with PTSD and mental health may lead to underreporting due to fear of organisational consequences and confidentiality loss; therefore, peer support programs, training, and wellbeing checks are essential to reduce long-term psychological distress (Mildenhall, 2012; Galderisi, Heinz, Kastrup, Beezhold & Sartorius, 2015). After exposure to traumatic stressors, one of the most effective tools to process the event is to debrief (Mildenhall, 2012). Talking about the event helps normalise feelings of sadness, guilt, blame, and anger (Mildenhall, 2012). Allowing the brain to put things into context and give meaning to an event so that it can be processed into a long-distance memory enables the individual to move on (Mildenhall, 2012). Not allowing time to process events and for our stress response to reset is not sustainable leading to a risk of developing emotional fatigue, burnout, and PTSD (Mildenhall, 2012).
There are notable similarities between stress as a result of exposure to traumatic events and PTSD (Sarnowska et al, 2018). They both deprive an individual of a sense of security and cause feelings of anxiety. Hyperarousal, one of the main factors associated with developing PTSD is characterised by sleep disturbances and fatigue (Hegg-Deloye et al, 2014). A report from Hegg-Deloye et al (2014), revealed that more than 80% of people with PTSD report months of sleeping difficulties after exposure to the shocking event. Eventually, poor morale and personal distress can progress to PTSD, whereby exposure to less traumatic events progresses to severe reactions over time (The Senate Inquiry into Mental Health, 2018).
Alongside the prevalence of PTSD among paramedics there is an increased risk for suicidality (Jones, 2017). Figures from The Senate Inquiry into Mental Health (2018) reveal the rate of suicide among paramedics is nearly four times higher than the average of all other Victorian jobs. Paramedics suffering from conditions such as PTSD and/or drug addictions have been known to steal and misuse addictive drugs from ambulances such as fentanyl, increasing the risk of suicide by overdose (The Senate Inquiry into Mental Health, 2018). Strategies implemented by Ambulance Victoria have however improved in recent years with strict protocols for checking and safe discarding of drugs of addiction (The Senate Inquiry into Mental Health, 2018). Furthermore, suicide prevention training as well as improved psychological screening has been implemented for new recruits in Ambulance Victoria to better manage mental health (The Senate Inquiry into Mental Health, 2018).
It is evident that further resources are required to support paramedics to recover from traumatic cases that trigger stress responses to enable paramedics to stay mentally healthy and reduce risks of psychological harm and suicide (The Senate Inquiry into Mental Health, 2018). One of the major impacts on paramedics is fatigue as a result of shift work. It is essential for paramedics to recognise the importance of sleep to be able to perform tasks methodically and confidently to ensure personal and public safety is maintained (Sofianopoulos, Williams & Archer, 2012). Recommendations to prevent fatigue, improve performance and reduce the risk of errors include napping before, during, and after night shifts (Sofianopoulos, Williams & Archer, 2012). In addition, evidence suggests regular physical exercise provides specific benefits for not only mood states and depression but also a reduction in fatigue symptoms (Courtney, Francis & Paxton, 2013). However, shift work poses a significant lifestyle implication that limits opportunities for regular exercise as well as difficulties in committing to sporting activities (Courtney, Francis & Paxton, 2013). The lengthy shifts required to be worked by paramedics and short rest periods between shifts hold significant implications for sleep cycles (Courtney, Francis & Paxton, 2013). Recommendations to limit shifts to ten hours would be beneficial in reducing fatigue and limit the risk of workplace accidents (Courtney, Francis & Paxton, 2013). Furthermore, improvements in fatigue symptoms among paramedics may see a decline in the prevalence of mental illnesses such as depression, stress, and PTSD (Courtney, Francis & Paxton, 2013).
Self-awareness of stress due to traumatic experiences is detrimental to paramedic’s health and well-being (Sarnowska et al, 2018). Understanding one’s own emotional reactions and managing them by undertaking appropriate actions including psychological therapy is of utmost importance to reduce the incidence of PTSD (Sarnowska et al, 2018). Adapting strategies to cope with stress undoubtedly helps eliminate its potential for destructive consequences (Sarnowska et al, 2018). Developing an awareness of the risks of occupational stress and exposure to trauma can be an effective strategy in developing improved resilience and mindfulness and thus creates a positive working career (The Senate Inquiry into Mental Health, 2018). Increased incidences of psychosis, drug and alcohol addictions, psychosomatic diseases, and suicide are potential consequences of chronic stress; thus, recognition of the source is of great significance (Sarnowska et al, 2018). Paramedics should be reviewed on a regular basis to assess aspects of stress within the workplace so that appropriate strategies can be implemented to identify issues and take action (The Senate Inquiry into Mental Health, 2018).
It has been identified that paramedic stress responses may be related to different coping styles (LeBlanc et al, 2011). Individuals who adopt task-orientated coping styles evidently have decreased anxiety levels, whereas emotional and avoidant coping styles were associated with greater anxiety and cortisol responses (LeBlanc et al, 2011). Coping mechanisms to stress can be modifiable, therefore, implementing interventions aimed toward paramedics to utilise task-orientated coping styles may be an effective measure in reducing stress responses as a result of traumatic events (LeBlanc et al, 2011). Effective communication channels, the creation of positive morale, and healthy work culture is vital to prevent paramedics from spiralling into a mental health disaster (The Senate Inquiry into Mental Health, 2018).
Paramedics are often faced with great emotional burdens through the heights of human emotion and trauma across all life spans. Such mental and physical stressors are associated with an increased risk of depression. The effects of shift work on paramedics has been researched with impacts on fatigue, work stress and low job satisfaction, contributing to poor mental and physical health. Furthermore, mental and physical fatigue is a major risk factor for adverse events, including personal injury and medical errors. Therefore, it is necessary to further develop prevention strategies through early intervention to ensure paramedics mental health is supported. The stigma associated with mental illness is particularly prevalent in paramedics as they typically pride themselves on self-reliance and strength. Thus, raising awareness and removing the stigma around mental health will also aid in paramedics seeking support. It is important for mental health to be seen as a vital element of the human condition and acknowledge the reality of risks of psychological harm. Education and understanding mental health early in one’s career as well as proactive moves is vital for cultural change. Ensuring paramedics are both physically and mentally healthy is essential in providing best patient care and overall benefit to the community, as well as the benefit to the individual and their colleagues.