Posttraumatic Stress in EMS Personnel

Introduction

Emergency medical service (EMS) workers often encounter distressing traumatic events, also known as critical incidents (Mitchell, 1983), due to the nature of their work. This generally involves treating critically injured individuals, acting promptly in critical circumstances, and attending cases where they witness threats to others (Regehr et al., 2003a; Regehr et al., 2003b). In addition, EMS workers are frequently exposed to various occupational hazards that put them at risk of harm, including violence (Regehr, Hill, & Glancy, 2000) or cases involving dealing with serious communicable diseases (James, 1988).

An Australian-based study showed that approximately 88% of paramedics experienced work-related violence over their career (Boyle et al., 2007). Previous studies have indicated that death of a patient are among the most distressing events experienced by first responders (Alexander & Klein, 2001; Clohessy & Ehlers, 1999; Van der Ploeg & Kleber, 2003), and caring for burned or severely injured patients was also deemed to be among stressful events. Other studies have indicated that dealing with dead bodies and human body parts are among the most distressing incidents identified by first responders (Regambal et al., 2015; Ursano et al., 1995).

The mental distress experienced by EMS workers could manifest as symptoms of anxiety, depression and PTSD, which can all contribute to suicidal ideation and suicide attempts (Nakao, Yamanaka, & Kuboki, 2002; Thoresen & Mehlum, 2006). Moreover, a study of EMS staff in Norway found that serious suicidal ideation correlated with emotional exhaustion and depression (Sterud et al., 2008). Ravenscroft (1994) and Rodgers (1998) found that the prevalence of PTSD among healthcare providers could be linked with sick leave, early retirement, and burnout cases. Furthermore, exposure to traumatic events has been strongly associated with poorer mental health consequences and reduced quality of life (McFarlane, 2010).

According to Donnelly (2012), exposure to critical incidents (acute stressors) along with daily operational demands (chronic stress) increases the risk of developing posttraumatic stress symptoms among EMS workers. Another study has shown that all EMS personnel are exposed to traumatic incidents (Regehr, Goldberg, & Hughes, 2002). Other studies have also observed high rates of traumatic incidents and common psychological consequences (Alexander & Klein, 2001; Clohessy & Ehlers, 1999; Regehr, Goldberg, & Hughes, 2002). A theoretical model is also presented to show the multifactorial associations of this subject.

Search strategy

This narrative review aimed at understanding the determinants of traumatic stress (acute stress) and its related psychological consequences in EMS workers. Studies related to other healthcare occupations, such as physicians and nurses working in emergency departments, have also been included, due to the similarity of their job characteristics that involve treating traumatised and severely injured patients. Studies involving first responders that included paramedics in their population will also be included. Studies focused on volunteer EMTs or other emergency responders such police officers and firefighters will be excluded. However, studies involved firefighter paramedics/medics will be included.

Both published and unpublished research was involved in the initial search strategy for relevant literature on the topic of PTSD occurrence among EMS personnel. Research studying human subjects and published in English as well as not limited to a particular geographical location was searched in the following databases: Ovid PsycINFO, Ovid MEDLINE, Web of Science and Google Scholar. Publication years of the articles did not represent a limitation for the search.

Keywords used for selecting articles included: EMS, EMT, PTSD, PTSS, emergency medical technician, acute stress, posttraumatic stress, pre-hospital, posttraumatic stress, critical incident stress, and pre-hospital. To facilitate the synthesis of data, full copies of articles resulting from the search were obtained; the articles had to meet the identified criteria for inclusion on the basis of their titles, abstracts, and descriptors of subjects. Studies found in articles’ reference lists and bibliographies were also considered for the potential data collection on the basis of their titles.

The data required for the current analysis was independently extracted by the reviewer, who then used Mendeley, a reference management survey, to generate the results from the databases and identify duplicate studies. Thematic analysis will be used; it represents an analysis tool for identifying common themes and codes within written materials.

Prevalence of posttraumatic stress symptomatology in EMS workers

EMS workers are at risk of developing psychological distress due to the occupational demands they face daily (McFarlane & Bryant, 2007; Mishra et al., 2010). A study of emergency department personnel found that 30% reported posttraumatic stress symptoms (PTSS), while 12% met the criteria for posttraumatic stress disorder (PTSD) (Laposa, Alden, & Fullerton, 2003). Further, a systematic review indicated that EMS workers exhibited the highest rates of PTSD compared with other emergency rescuers (Berger et al., 2014). This was also evidenced by a recent meta-analysis that found a high prevalence of PTSD among EMS workers, including approximately 11% of ambulance staff (Petrie et al., 2018).

A study conducted in the UK examined the pre-trauma risk factors for PTSD and depression showed that newly employed paramedics exhibited significant symptoms of PTSD. Nearly 8% of the participants developed symptoms of PTSD during training phase, which affected their functioning (Wild et al., 2016). The authors implied that despite nearly all of the participants encountered at least one traumatic event during their 2-year training; most of them did not develop symptoms of PTSD or depression.

Lubin et al. (2007) studied the occurrence of acute stress disorder (ASD) and PTSD among medical personnel (141 medicals and 19 doctors) specialising in providing emergency health care services during 23 emergency events. The findings were surprising as PTSD was found to be extremely rare in the studied population, occurring in only one medic. ASD, however, was found in one doctor and 12 medics. Therefore, the scholars concluded that the occurrence of PTSD in emergency personnel is not stable and depends on the population that is being researched. While the general lifetime prevalence of PTSD is estimated at around 8%, the findings of the study involving emergency care workers are inconsistent.

According to the study by Kosydar-Bochenek et al. (2017), traumatic stress in the work of paramedics represents a significant challenge to addressing the problem of PTSD development. The estimated rate of PTSD occurrence among paramedics is 20%, which means that a fifth of professionals operating in this sphere is faced with mental health challenges at some point or another. Swedish studies, on the other hand, found that PTSD occurs in 10-17% of paramedics; this shows that the geographical position of workers may have an impact on different rates of the disease’s prevalence.

Essential findings regarding the occurrence of PTSD among EMS personnel were provided by Skogstad et al. (2013) as the researchers differentiated between the various specializations to go in-depth into the issue. For example, emergency health care professionals, especially nurses working at intensive-care units and mental health care wave shown to hive higher rates of PTSD occurrence. Conversely, police officers, who are closely involved with responding to emergency situations, had a PTSD rate of less than 10%, which shows that the professionals in the health care field are more likely to suffer from mental distress.

Mishra et al.’s (2010) contribution is notable because of the differentiation between PTSD criteria and their occurrence among EMS personnel. The measure of exposure occurred in 22% of respondents, while the criterion of re-experiencing occurred in 27% of the surveyed EMS workers. The criterion of avoidance was relevant for 8% of participants. The two most severe criteria of PTSD, hyperarousal and impairment in functioning, occurred in 26% and 29% of respondents, respectively. The criteria of PTSD refer to the extent to which EMS professionals experience the condition and can be useful in further diagnosis and intervention.

Fjeldheim et al. (2014) explored the occurrence of PTSD among paramedic trainees. 94% of assessed paramedic trainees had a direct experience of trauma and 16% qualified for PTSD symptomology. This shows that the early exposure of trainees to trauma and risky situations will inevitably increase their risks of developing PTSD in the future. McFarlane, Williamson, and Barton (2009) found that the prevalence of PTSD among emergency service workers was between 6% and 32%. The occurrence of the disorder was attributed to various pre-existing factors ranging from biological markers to prevention strategies implemented prior to the occurrence of stressful situations.

A multi-dimensional study by Berger et al. (2012) provided an insight into the occurrence of PTSD among EMS workers worldwide, pointing to the differences in the disease’s prevalence in different geographical locations. The global pooled occurrence of PTSD was 10%, with workers in Asia having an higher estimated prevalence of the disease compared to European emergency personnel. The estimates for North America were similar to those for Asia. Ambulance personnel arriving at emergency sites showed higher rates of estimated PTSD as compared to police officers and firefighters.

Luftman et al. (2017) analysed surveys provided by 546 EMS providers, and no differences were found in screen positivity for gender, region, and age. However, pre-hospital healthcare personnel was more likely to show PTSD symptoms compared to those providing care at facilities: 42% as compared to 21%, p<0.001. Notable findings include the fact that only 55% of survey respondents received education on PTSD, and only 13% ever sought treatment for addressing the impact of the disease. These results are alarming and point to the need to increase the awareness of PTSD among health care personnel.

Petrie et al. (2018) supported the findings of Luftman et al. (2017) by finding that ambulance personnel had the highest likelihood of developing PTSD as compared to other emergency responders. The estimated prevalence rate of mental health complications among emergency personnel was 11% for PTSD, 15% for depressive symptoms and severe depression, 15% for anxiety, and 27% for overall psychological distress. The exposure of ambulance personnel to the immediate trauma of emergency situations contributed to their likelihood of developing complex mental conditions. These findings were supported by Jones et al. (2018), who implemented a survey for measuring the occurrence of psychiatric symptoms among the first respondents. 26% of participants reported significant PTSD symptomology, 31% showed harmful behaviours associated with excessive alcohol use, 93% reported considerable disturbance of sleep, and 34% showed a high risk of suicide.

Gómez-Gutiérrez et al. (2016) found that symptoms of PTSD were increasingly high among pre-hospital emergency professionals who were assaulted by patients and/or their relatives. It was revealed that over a third (34.5%) of surveyed participants had been physically attacked during their work as first respondents. 75.3% of surveyed participants were verbally insulted, while 76.2% were slandered (Gómez-Gutiérrez et al., 2016). It is also important to mention that 15.2% of respondents were witnesses of physical violence against their partners, and only 18.1% of first responders did not experience any level of aggression (neither physical nor emotional) when doing their work. The occurrence of abuse targeted at pre-hospital emergency personnel inevitably increased their likelihood of developing PTSD, which points to the need to explore this issue in greater detail in the future.

In the Swedish context, Jonsson, Segesten, and Mattsson (2003) studied the occurrence of PTSD among ambulance personnel through surveying 362 professionals. Of individuals reporting the exposure of traumatic situations, 15.2% scored 31 and higher on the IES-15 subscale, indicating a stressful reaction with a specific likelihood of PTSD development. Om the PTSS-10 scale, 12.1% of respondents scored 5 and higher, which is an indicator of a relatively strong reaction to a stressful situation. Significant predictors of PTSD development in the population of ambulance personnel included extensive experience of working in the profession, their age, as well as both physical and psychological workload.

A Norway study conducted by Ekeberg and Hem (2006) explored the health status of ambulance service workers due to the need to consider work-related health issues. The most important finding of the study refers to showing that workers providing ambulance services had a higher standardized rate of mortality, a higher occurrence of accidents and injuries leading to death, as well as a higher rate of standardized early retirement. These issues are accompanied by mental health complications among the population, including anxiety and generally poor psychopathology. While the study did not find any evidence for ambulance workers suffering from a higher prevalence of psychological disorders compared to the general working population, it is crucial to consider in the context of exploring PTSD occurrence.

Following up on the study of PTSD among emergency medical personnel in different geographical contexts, it is essential to mention the article by Berger et al. (2007). The researchers conducted a cross-sectional survey of PTSD involving 234 Brazilian ambulance workers. 5.6% of respondents exhibited signs of full PTSD, while 15% of participants reported partial PTSD. In terms of the full manifestation of the disorder, the symptoms were reported by 6.7% men and 1.9% women. The results for partial PTSD were reverse: 20.4% of women and 13.3% reported their occurrence.

In the Canadian context, Carleton et al. (2018) studied mental disorder symptoms among the personnel specialising in public safety. 49.1 % of paramedics involved in the study showed positive results for recent mental disorders. Although published more than two decades ago, the study by Grevin (1996) is vital to the discussion of PTSD occurrence among paramedics. According to the findings of the researcher, 20% of experienced paramedics and 22% of those studying to become professionals appeared to suffer from trauma as classified by the MMPI-2 scale. Both professionals and trainees reported significantly high Denial and Repression scores on Regression and Reaction Formation; however, the mental health implications of these scores remain unclear.

The study by Bennett et al. (2004) explored the levels of mental health issues in the context of United Kingdom emergency ambulance workers. Among the participants of the study, the overall rate of PTSD was 22%, which is more than a fifth of ambulance workers in the UK. Nearly one in ten participants reported a higher likelihood of clinical levels of depression, and 22% reported probable levels of clinical anxiety. While the data collected to the study was self-reported and thus had a certain degree of bias, the findings are important for suggesting that workers in ambulances are highly likely to experience symptoms of PTSD that lead to potentially adverse mental health implications.

Critical incident Stress and characteristics of critical incidents identified by EMS personnel

Employees in high-risk occupations such as paramedics, firefighters and other emergency rescuers are often exposed to acute stressors or critical incident stressors (Van der Ploeg & Kleber, 2003). Their roles expose them repeatedly to traumatic incidents that provoke these stressors. All paramedics were exposed to at least one critical incident over their career (Regehr et al., 2002). According to Mitchell (1983), critical incidents are recognised as stressful occupational events that can induce acute stress and diminish the functioning of individuals in either the short or long term.

This definition is supported by Halpern et al. (2014), who identified critical incidents as cases causing uncommon, extremely overwhelming emotions, either because of the event itself, the worker’s response to it, or any other job-related reason. Previous studies identified the types of critical incidents based on the features of the event, including patient characteristics (e.g. a severely injured child), situational characteristics (e.g. on-scene threats or hazards), or personal characteristics (e.g. lack of control or feeling helpless) (Alexander & Klein, 2001; Clohessy & Ehlers, 1999; Halpern et al., 2009; Regehr, Goldberg, & Hughes, 2002).

Alexander and Klein (2001) identified critical incidents as events that are exceptionally disturbing, thus affecting the individual’s normal coping strategy. Caine and Ter-Bagdasarian (2003) defined critical incidents as overwhelming events that have an emotional influence sufficient to affect the worker’s effective coping strategy, leading to psychological distress. Some may exhibit a prolonged or strong response to a critical incident that puts them at risk of developing health disorders (Selye, 1950). According to Halpern et al. (2009), incidents that were categorised as critical among EMS personnel were those that involved death in combination with a tragedy.

These events may cause vulnerable feelings of helplessness and extreme compassion, which can then lead to further emotional, cognitive and behavioural reactions (Halpern et al., 2009). Notably, a critical incident is not necessarily a significant or major event; it can be identifying with a dying patient or accidentally harming a patient (Boland et al., 2018).

Donnelly (2010) emphasized that critical incident stress is associated with the provision of emergency care and the emotional sequelae resulted from experiencing traumatic events. The author also noted that critical incidents could be conceptualized as a single incident or the result of more than one traumatic incident (e.g. dealing with multiple death cases in a short period of time). Critical incident stress that is resulted from dealing with multiple traumatic events has the potential to increase the risk of adverse mental health outcomes. Consequently, exposure to multiple critical incidents (traumatic events) is associated with high level of posttraumatic stress symptomatology, thus increasing the risk of posttraumatic stress, in particular PTSD (Beaton, et al., 1995; Bryant & Harvey, 1996; Ward, Lombard, & Gwebushe, 2006) PTSD has been notably documented in the literature and frequently associated with the high exposure of EMS workers to critical incidents (Sterud, Ekeberg, & Hem, 2006).

Boland et al. (2018) found that the most stressful events identified by EMS workers involved cases with children, patients known to the workers, or a medical error that led to deterioration in the patient’s condition. Most studies indicated that cases involving severely injured children were among the most distressing (Clohessy & Ehlers, 1999; Alexander and Klein, 2001; Regehr et al., 2002; Ploeg and Kleber, 2003; Minnie, Goodman and Wallis, 2015; L. L. Boland et al., 2018).

Other stressful incidents described in these studies included treating burned or severely injured patients, mass causality incidents, road traffic accidents, murder cases and other dead patients, and handling the body parts of a dead patient. Evidence showed that elements operating during or after the trauma (e.g. social support and severity of the experienced trauma) are more significant in terms of their influence on the traumatic reaction than pre-trauma elements (e.g. previous childhood trauma) (Brewin, Andrews, & Valentine, 2000). In this review, the term “critical incident” is used interchangeably with “traumatic event”.

The study by Marmar et al. (1996) is important to consider when exploring PTSD occurrence as related to exposure to critical incidents. The scholars studied the experiences of rescue workers responding to the Loma Prieta earthquake in the San Francisco Bay Area in 1989 as well as emergency care personnel that had no connection to the disaster. Based on the findings of the researchers, subjects exhibiting significant levels of peritraumatic dissociation were characterized as younger and had higher exposure to traumatic incidents. Therefore, the development of PTSD among the population was associated with the experiences of the perceived threat and lower scores of adjustment in general.

Important conclusions related to the study are associated with the implication that rescue workers who are uncertain of their leadership roles and identity are more likely to have issues coping with the exposure to traumatic incidents. Emotional suppression and wishful thinking contributed to the higher risk of the population developing acute dissociative responses to severe trauma as well as subsequent PTSD.

Expanding on the previous study, Marmar et al. (1999) studied the progression and predictors of stress-related and overall symptomatic distress among EMS personnel. The occurrence of adverse psychological symptoms after the exposure to critical events was associated with the variance in experiences, issues with adjustments, social support, locus of control, as well as general dissociative tendencies. As compared to the prior 1996 study, there were some improvements in avoidant symptoms of PTSD as well as enhanced interpersonal functioning within the target population. This showed that with time, the preoccupation with traumatic events is likely to diminish while hyperarousal remains, thus pointing to the possible biological autonomy of arousal responses in reaction to trauma exposure. These findings describe the natural history of PTSD symptoms over time for individuals exhibiting mild but persisting levels of symptomatic responses. While intrusive symptoms decrease in impact, general anxiety and depression may persist.

Gallagher and McGilloway (2008) examined the impact of critical incidents (CIs) on the psychological well-being of frontline ambulance personnel. The study was conducted due to the need to collect evidence about the influence of Cis on the personal and professional lives of ambulance workers. By interviewing EMS professionals with recent experience of critical incidents, the researchers focused on studying their attitudes to support services and addressing barriers to service use. According to the self-reported data provided by study participants, there was a diverse range of both physical and psychological health issues, including difficulties sleeping, outbursts of anger, as well as irrational feelings of alienation.

The likelihood of mental health complications was attributed to the absence of supportive tools available to the personnel, the lack of consideration on the part of emergency personnel management, as well as the need to receive professional counseling services and training on stress awareness. Emergency Medical Controllers (EMCs) also showed a higher likelihood of mental health issues associated with the complications inherent to their role within the profession. The exposure to CIs decreased the quality of health and well-being, with important implications being associated with limited efforts of addressing both the training and health needs of the personnel.

According to Avraham et al. (2014), exposure to CIs presents a challenge to paramedics’ emotional, cognitive, and behavioral stability. The researchers involved paramedics working in the Israel context to determine how they deal with many traumatic experiences. After interviewing 15 participants from Israel, it was found that there was a link between connection and detachment as well as between the lack of control and control over a situation. Those paramedics who sensed a lack of control over a situation were more likely to experience negative emotions. To achieve detachment from CIs, a variety of coping strategies were implemented.

Posttraumatic stress symptomatology following critical incidents

The trauma experienced by emergency responders can have an adverse psychological effect, putting them at risk of developing posttraumatic stress reactions, in particular posttraumatic stress symptoms and posttraumatic stress disorder (Fullerton, Ursano, & Wang, 2004, donnelly, 2011). The usual response to traumatic incidents involves a variety of potential posttraumatic stress symptoms (PTSS), which generally include symptoms of re-experiencing the traumatic event (e.g. intrusion, recurrent nightmares and flashbacks), avoidance of whatever is related to the trauma stimuli and emotional numbing (e.g. avoiding people, places and thoughts related to the incident), and hyperarousal (e.g. lack of concentration, increased irritability, and sleep problems) (American Psychiatric Association, 2013; Jackson et al., 2007). These symptoms improve over time in most individuals (Rothbaum and Davis, 2003).

However, if these symptoms last for a month, then they meet the diagnosis for PTSD (American Psychiatric Association, 2013). PTSD has been well acknowledged in EMS literature more than other mental disorders. PTSD which has been classified as trauma and stressor-related disorders in the DSM-5, is a psychiatric condition that results from exposure to a distressing event (trauma) either by experiencing the trauma itself (direct exposure), witnessing it (in person), knowing that someone close was exposed to trauma (indirect exposure), or frequent or extreme exposure to the aversive details of that traumatic event (indirect exposure).

The diagnostic criteria for PTSD requires the existence a stressor (criterion A), along with symptoms of intrusion (criterion B), avoidance (criterion C), negative mood and cognitive changes (criterion D), increased arousal (criterion E), duration of these symptoms for at least a month (criterion F), notable functional impairment caused by the induced distress (criterion G), and that these symptoms are not related to substance abuse, medications or other conditions (criterion H). These symptoms shall begin or worsened following exposure to trauma. Moreover, new subtype for PTSD was added in the 5th version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) that include symptoms of dissociative (American Psychiatric Association, 2013).

The frequent exposure of EMS workers to PTSS and the persistence of these symptoms could lead to a range of mental disorders (Davis et al., 2019). A review by de Boer et al. (2011) revealed the existence of a positive relationship between exposure to critical incidents at work and PTSS in healthcare professionals working in hospitals. In the first month following a critical incident, an individual may experience PTSS without meeting a diagnosis of PTSD. Severe PTSS that appear within two days to four weeks following a critical incident is recognised as acute stress disorder (ASD), that is also classified as a trauma and stressor-related disorders in the DSM-5 (American Psychiatric Association, 2013; Bryant, 2017).

The symptoms of ASD overlap with the symptoms of PTSD. ASD requires at least three dissociative symptoms, along with symptoms of avoidance, intrusion and arousal, whereas PTSD does not require dissociative symptoms (American Psychiatric Association, 2013). Dissociative symptoms include detachment or numbness, lack of awareness, disconnection from reality, forgetting details about the distressing incident, and depersonalisation (American Psychiatric Association, 2013). Further, the Diagnostic and Statistical Manual for Mental Health 5th edition (2013) has included in the PTSD diagnosis a subtype for dissociative symptoms when presented (American Psychiatric Association, 2013). Exposure to traumatic events increases the risk of ASD among pre-hospital EMS workers, which is a risk factor for the development of PTSD (Smith & Roberts, 2003).

A study of Scottish EMS workers found that approximately half had high levels of PTSS, and that PTSS was directly linked to psychological inflexibility (Davis, 2017). In this context, psychological flexibility involves a number of characteristics, including the capability to recognise and adjust to various situational demands, obtaining a balanced life, shifting mindsets when needed, and being committed to actions that represent deeply held morals and values. The absence of these characteristics could lead to the development of mental health problems (Kashdan & Rottenberg, 2010). Therefore, psychological inflexibility is arguably associated with increased levels of mental health problems and higher levels of PTSS. In this context, Davis (2017) suggested the need for further evaluation of the relationship between psychological flexibility and PTSS.

While noting the causality and impacts of posttraumatic stress, Regambal et al. (2015) stated that though first responders routinely experience traumatic events due to the nature of their occupation, their PTSD symptoms are considered relatively low. The authors found that both uncontrollability and limited resources were linked to dissociative experiences during a traumatic event resulting in PTSD symptoms. Dissociation could be a coping strategy used by these individuals to minimise the effect of stressful incidents on their emotions and wellbeing, particularly when dealing with traumatised patients or horrifying events. This was also affirmed by Foa, Zinbarg and Rothbaum (1992), who observed that unpredictable or uncontrollable events are more likely to cause symptoms of PTSD. Despite the difference between PTSS and PTSD, the terms have been used interchangeably in the literature.

Other psychological consequences of exposure to traumatic events

Moreover, Regehr, Goldberg and Hughes (2002) reported that elevated distress levels among EMS workers were associated with the development of secondary traumatic stress (STS) as a result of dealing with traumatised patients. According to Cieslak et al. (2013), STS is a PTSD-like reaction that results from indirect exposure to trauma, such as dealing with traumatised individuals. EMS workers are at higher risk of experiencing symptoms of STS when they develop an empathetic relationship with traumatised individuals (Regehr, Goldberg, & Hughes, 2002). STS has been used interchangeably with “compassion fatigue” and “vicarious trauma” in the literature, and has been mostly examined in mental healthcare providers (Cieslak et al., 2013).

Although exposure to critical incidents had not been associated with burnout among EMS personnel (Boland et al., 2018), a systematic review showed a strong relationship between burnout and STS in workers exposed to indirect trauma (Cieslak et al., 2014). This was affirmed a longitudinal study (Shoji et al. 2015) that examined the relationships between STS and burnout in a group of healthcare professionals. The results of the study demonstrated that burnout is a risk factor for the development of STS. Research has shown an association between professional burnout and low quality of care in the healthcare setting (Leiter, Harvie, & Frizzell, 1998).

Cieslak et al. (2014) defined occupational burnout as a mental health disorder common among individuals working in stressful professions. Similarly, Maslach and Jackson (1981) defined it as “a syndrome of emotional exhaustion, depersonalisation and reduced personal accomplishment that is common among individuals who do ‘people work’ of some kind”. Burnout consists of three distinct components: emotional exhaustion, depersonalisation and lack of personal accomplishment (Maslach and Jackson, 1981).

Research has indicated that burnout is positively linked to the issues of turnover and absenteeism among paramedics in the US (Crowe et al., 2018; Fragoso et al., 2016). Another study reported that the prevalence of burnout cases among emergency department healthcare workers was significantly high and associated with intent to leave the profession (Hamdan & Hamra, 2017). High turnover rates could result in the loss of highly productive emergency care staff, thereby affecting the service quality. Hamdan and Hamra (2017) indicated that high burnout level was a result of having to deal with life-threatening cases and severely traumatised individuals in Palestinian emergency departments, and these events also contributed to the high levels of emotional exhaustion experienced among emergency healthcare staff.

Burnout has also been correlated with detrimental mental health outcomes among healthcare providers, which could negatively impact service quality (Hamdan and Hamra, 2017). This is also evident from the review by Williams et al. (2017), which noted a relationship between empathy and burnout. High burnout levels could result in low empathy among workers (Williams et al., 2017), and could lead to negative attitudes towards patients, affecting the quality of care. Moreover, Crowe et al. (2018) demonstrated a correlation between high burnout and stressors in the EMS setting, finding that stressors exposed workers to a high risk of burnout, that resulted in significant workforce loss. The study confirmed a link between work-related burnout and turnover intentions. Previous studies also reported that doctors and nurses with high burnout levels had greater intentions to leave their occupation (Maslach, Schaufeli, & Leiter, 2001; Aiken et al., 2002; Poghosyan et al., 2010).

Hamdan and Hamra (2017) found that emergency care providers who were exposed to violence at work reported higher levels of depersonalisation and anxiety. Maslach, Schaufeli and Leiter (2001) defined depersonalisation as a cynical feeling that one holds against their workplace, which is reflected in lack of concern and compassion for others, leading to direct implications for service quality levels (Alexander & Klein 2001; Williams et al., 2001; Leiter & Maslach, 2009; Williams et al., 2017). Brough (2004) and Fernanda et al. (2014) noted that elevated stress levels among healthcare staff also led to a reduced capability for and interest in providing the best quality of service to patients. This could also manifest in staff detaching from the stressful work environment, which may result in negative attitudes towards patients, representing lack of empathy and concern towards patient needs and feelings.

Empathy is an essential element in the provision of care. According to Brough (2004) and Fernanda et al. (2014), empathy facilitates communication between the healthcare provider and their patient, resulting in a positive relationship. This positive relationship could act as a protective factor for the healthcare provider against burnout (Hojat et al., 2015; Thirioux, Birault, & Jaafari, 2016). Empathy facilitates reduction of anxiety and distress, as evidenced by Williams et al. (2017).

Predictors of Posttraumatic stress symptomatology among EMS workers

A number of past studies have identified the predictors of post-traumatic stress symptomatology in paramedics. Some of the most predominant factors include the characteristic of the critical incident. In other words, incidents involving children are substantial predictors of PTSD. Furthermore, events which are classified as chaotic and in which the paramedics have limited resources have been associated with higher rates of post-traumatic stress symptomatology. In addition, if the individual has had a past trauma or they have a history of mental illness, they are more likely to develop PTSD. Other factors that have been identified are dissociation, the coping strategies that are used by the paramedic, social support and communication in the organization, and organizational stress. More research is required to conclude the effects of age and gender on the post-traumatic stress symptomatology as prior research has found mixed results. these predictors are discussed below.

Individual characteristics

History of mental disorder and past trauma

Wild et al. (2016) indicated that newly employed paramedics with a history of mental disorder were at higher risk of developing PTSD and symptoms of depression during training period. The study revealed that rumination about stressful incidents, which occurred before the commencement of training was a predictor of PTSD. In addition, a study by Maunder et al. (2012) concluded that paramedics who had experienced childhood trauma, physical, emotional, or sexual abuse were especially predisposed to experiencing acute stress in response to critical incidents.

The study by Jones, Nagel, McSweeney, and Curran (2018), the history of psychiatric disorders among first responders plays a vital role in predicting the occurrence of PTSD in this target group. Important considerations are necessary to account for moderate-severe and severe anxiety symptoms, alcohol dependence, high risk factors for suicidality, as well as other psychiatric disorders that make the occurrence of PTSD more likely. These findings were also supported by Avraham et al. (2014), who identified that the lack of control over one’s mental well-being prevented EMS personnel from detaching themselves from the memories of past trauma. Cognitive and functional control was imperative for facilitating positive and empowering experiences.

Marmar et al. (1999) suggested that the presence of chronic symptomatic distress among EMS personnel increased their likelihood of developing complex mental health disorders such as PTSD. The dissociation of individuals occurring at the time of exposure to trauma was also a predictor of distress.

Personality traits

Paramedics with a personality trait of neuroticism (Wild et al., 2016) and dissociation (Bennett et al., 2005; Skogstad, Fjetland and Ekeberg, 2015) were more susceptible to develop symptoms related to PTSD and suffer from depression. According to Jones (2013), considering the personality traits of first responders is essential for predicting the occurrence of PTSD in the future. For example, the exposure of critical incidents is more likely to lead to adverse mental health consequences when there is a history of negative psychopathology and its influence on personality.

With regards to the personality traits, paramedics who display insecure attachment, more specifically fearful-avoidant insecure attachment, were more likely to display current post-traumatic stress symptomatology (Halpern et al., 2011). Furthermore, the study also noted that insecure attachment was also linked with maladaptive coping strategies, limited social support as well as slower recovery from social withdrawal post-incident. The ability to regulate emotions has also been identified to be a significant predictor of post-traumatic stress symptoms (Shepherd and Wild, 2014a). To assess the impact of personality traits on PTSD development, Marmar et al. (1996) suggested using the Hogan Personality Inventory that would show how prudent were individuals in addressing their mental health issues.

Coping Strategies

Paramedics using avoidant coping styles such as wishful thinking and behavioral disengagement were more at risk of developing PTSD (Wild et al., 2016). In addition, a study by Halpern et al.,

(2011) has found that there is a correlation between maladaptive coping strategies – including self-blame, behavioral disengagement, and denial, among others – and current post-traumatic stress symptomatology. Another study by Shepherd and Wild (2014b) measured the indirect effect of coping on post-traumatic stress through negative/positive event appraisals. It was found that the individuals who coped well with the event, gave more positive appraisals and hence were less susceptible to post-traumatic stress symptomatology. The results also indicated that those paramedics who did not cope well provided negative appraisals and displayed a higher degree of post-traumatic stress symptoms.

Kucmin et al. (2018)(Kucmin et al., 2018a) measured the role that different coping strategies (avoidance coping, active coping, and looking for support & focusing on emotions) and dispositional optimism play in increasing the risk of developing post-traumatic stress following a critical incident. The results indicated that the coping strategy associated with focusing on emotions was a significant predictor of the intensity of post-traumatic stress while on the other hand, dispositional optimism was a negative predictor of the same.

As mentioned by Spyros et al. (2008), the inadequate reaction to the continuous exposure to trauma contributed to the higher likelihood of PTSD development. EMS personnel who were more proactive in problem-solving and took up leadership roles were less likely to develop PTSD symptoms because these actions improved their coping strategies and facilitated the reaching of positive mental health outcomes. Thus, the inability of EMS professionals to initiate the process of workplace improvement when addressing PTSD development is likely to lead to the occurrence of the disorder within the target population.

Gender & age

A study by Ward, Lombard and Gwebushe (2006) did not find any difference in the rate of post-traumatic stress symptoms but found that women displayed greater general depression and anxiety in relation to incident exposure. In contrast, Bennett et al. (2005) found that men were more susceptible to develop post-traumatic stress symptomatology in comparison to women. As has been noted above, Maunder et al. (2011) found that paramedics with past history of personal trauma were more likely to experience acute stress, the study also found that women were more likely to be sexually abused thereby increasing the rate of predisposition of women to experiencing post-traumatic stress symptomatology.

An important finding regarding the influence of gender on the occurrence of PTSD was noted in the study by Jones et al. (2018), who studied the impact of various predictive factors on the development of the disorder. The researchers noted that being female increased the subjects’ likelihood of experiencing significant mental health issues, including depression, anxiety, and suicidal thoughts apart from PTSD. Women had a higher probability of exhibiting ‘internalizing’ disorders, while men showed ‘externalizing’ disorders (Jones et al. 2018).

Female emergency personnel are a minority in the male-dominated profession of emergency respondents and thus face increased physical demands, negative attitudes from their male co-workers, as well as harassment. Besides, Berger et al. (2012) support the findings of Jones et al. (2018) in concluding that the female gender has been consistently linked to the higher likelihood of PTSD development. On the other hand, it is notable that Bennett et al. (2003) found that prevalence rates for PTSD were higher for men, while the rates of anxiety and depression did not differ to a great extent. However, due to the unequal distribution of males and females in the emergency personnel profession, the findings regarding the prevalence of mental health disorders should be used with caution.

Women were more likely to show positive results for the screening for mental health disorders (Carleton et al., 2018). However, there was a statistically significant difference between genders in the category of police workers and firefighters, which means that the population of paramedics did not show any significant differences for PTSD occurrence among men and women. These findings are opposite to those provided by Jones et al. (2018), who found that females operating in the EMS profession were more likely to exhibit PTSD symptoms. The geographical location of the surveyed participants also plays an important role.

With regards to age, it has been hypothesized that age plays a moderating role on the relationship between predictors and post-traumatic stress symptomatology (Donnelly and Siebert, 2009). Also, it is notable that Spyros et al. (2008) also found that ambulance personnel of older age and more extensive experience were more likely to exhibit stress symptoms contributing to PTSD. Older age was directly linked to the increased exposure to traumatic emergency events.

Organizational factors

A study by Wild et al. (2016) showed that low social support at work increase the risk of PTSD and depression. Organizational factors can be categorized into acute stressors and chronic stressors. A longitudinal study carried out by van der Ploeg and Kleber (2003) with a sample of 123 ambulance workers in the Netherlands found that while there was no correlation between acute stressors and long terms health effects, chronic stressors, in particular, lack of social care from supervisor and colleagues, as well as poor communication in the work place, strongly correlated to long term symptomatology associated with post-traumatic stress, fatigue and burnout.

Another study by Bennett et al. (2005) measured the influence of organizational stressors such as conflict between colleagues, false alarms, and tension between home and work and found that these factors were much more likely to enhance the severity of PTSD symptoms among ambulance workers. In addition, one of the most significant predictors of post-traumatic stress symptomatology has been identified as organizational stress and incident stress (Donnelly et al., 2016).

Work characteristics

Exposure & reaction to critical incidents

According to Wild et al. (2016), the total number of traumatic events experienced by paramedics during their training period was not correlated with the risk of PTSD. However, the authors pointed out that a person’s response to the traumatic event predicted PTSD levels.

A study by Bennett et al. (2005) found that there was an influence of the frequency with which the ambulance workers experienced traumatic events, their length of service with the medical facility and the extent of their dissociation as a response to the incident on the severity of post-traumatic stress symptoms. However, a study by Halpern et al., (2011) has found no relationship between the reaction to acute stress and the time taken to recover from these reactions with current post-traumatic stress symptomatology. Furthermore, the number of critical incidents did not make any significant contribution to the current post-traumatic stress symptomatology

On the other hand, Regambal et al. (2015) has found that if the paramedics perceive the critical incident as chaotic and with resource limitations, they engage in a higher rate of dissociation during the event which is then related to a higher rate of post-traumatic stress. Another study by Ward, Lombard, and Gwebushe (2006) measured the relationship between the rate of exposure to critical incidents and post-traumatic stress symptomatology and found that with a higher exposure, the intensity of symptoms increased. Moreover, trauma exposure and peritraumatic responses measured as Avoidance, Numbing, Hyperarousal, and Intrusion served as critical predictors of post-traumatic stress symptoms (Declercq et al., 2011).

In addition, the authors also noted that where the trauma involved incidents with children, the occurrence of post-traumatic stress symptoms was higher. Furthermore, similar to Regambal et al. (2015), the study by Declercq et al. (2011) also noted that higher post-traumatic stress symptoms were more prevalent when the event was categorized as being chaotic with limited resources. However, a study by Skogstad, Fjetland and Ekeberg (2015) found no correlation between the exposure to critical incidents in Norway’s terror sites to higher rates of post-traumatic stress symptoms.

Burnout is an important aspect to consider because it represents a reaction to critical incidents because it contributes to the overall negative attitude of professionals to their job. Jones (2017) mentioned that burnout and related job dissatisfaction increased occupational stress and contributed to the occurrence of PTSD among emergency personnel. Those who are in the profession for long times and do not have enough resources and support to recover from incidents are greatly subjected to the development of PTSD symptoms. Burnout occurs when professionals are at a frequent exposure to incidents, and this exposure builds up to result in excessive stress and the declining desire to keep going. Burnout contributes to mental health concerns such as PTSD in cases when it remains unaddressed and overlooked.

General work conditions

Mishra et al. (2010), who studied trauma exposure and PTSD symptoms among emergency medical personnel, found that general work conditions were instrumental in increasing overall levels of stress among the target population. These conditions also include conflicts that exist between work demands and home life, which contribute to the increased pressure of having to deal with the problem. Shift work and frequent flyer calls are also significant contributors to rising mental distress of emergency response workers and their likelihood of developing PTSD. Therefore, establishing a positive work environment is imperative for strengthening the psychological well-being of emergency personnel.

According to the research by Skogstad et al. (2013), workplace conditions play an essential role in preventing the occurrence of PTSD. The three preventive strategies recommended to implement in the workplace include valid pre-employment selection, early intervention, and consistent training in stress management.

Rybojad et al. (2016) also explored the impact of various risk factors on PTSD development among paramedics and found that professionals working under the employer’s contract were more likely to report the disorder’s occurrence as compared to those who were self-employed. Thus, since paramedics are hired in different ways, it is crucial to consider their work conditions as related to disorder development. Individuals who were more educated were also more prone to experiencing PTSD.