The systematic review established that considerable interest has been directed towards concerns that: [14]

… practitioners who work in pre-hospital care may develop burnout and psychiatric disorders, in particular, and that they may develop post-traumatic stress disorder as a result of attending critical incidents. However, the methods used by most of the studies in our sample were not able to answer … questions [about the frequency of diagnoses and other conditions] because they used cross-sectional surveys with convenience samples and self-report questionnaires, which are not diagnostic tools. They considerably over-estimate the incidence of these problems, as demonstrated by the one high quality study which conducted clinical interviews and found that … a small[er] percentage of employees met criteria for PTSD or major depression, and that most resolved over a few months.

However, the high scores on these questionnaires probably indicate that PHEM practitioners often suffer considerable stress and distress. The sources of this stress are not as likely to be, as has often been thought, attending unusual and perhaps high-profile incidents, but more related to daily organisational and operational hassles such as unsupportive managers and a high volume of work to be done despite lack of resources.

Problems most affecting PHEM practitioners identified during the teams’ interviews with them

The Team found that a number of conditions that were commonly reported by practitioners and pre-hospital emergency trainees.

Distress

Distress is the most common impact of working in pre-hospital care settings. Distress is not a disorder but may accompany disorders. Some of the literature refers to distress being comprised of symptoms of anxiety, depression, or post-traumatic stress disorder. Most people report symptoms on self-completed questionnaires that do not reach cut-off levels that might indicate that they should be assessed to determine if a diagnosis of a common mental disorder is indicated on clinical grounds. Another approach involves considering the range and severity of people’s experiences against a checklist of common experiences that have been reported in previous incidents. Often the range of experiences considered is broader than the symptoms of common mental disorders [6, 8, 10]. Perhaps the most practical approach is based on people’s subjective descriptions of what they have experienced. A useful definition of distress during and after emergencies is based on the observation that [6, 8]:

People are likely to feel stressed in emergencies and incidents. Their experiences are described as distress when they are accompanied by emotions, thoughts, and physical sensations that are upsetting or which effect their relationships. Recent research shows that common experiences that people describe as distress include feeling upset; fear; anxiety; fear of recurrence of the event; vigilance at social gatherings and in public places; avoiding uncomfortable feelings; and social withdrawal [6, 8]. The main differences between distress and the symptoms of common mental health problems lies in the trajectory of people’s recovery and the severity of their experiences. Until recently, the literature has tended to underestimate the number of people who take a long time to recover.

Practical aspects of these matters are illustrated by four papers [5,6,7,8].

Fatigue

Three main sources of fatigue are [10, 27]:

•Working at unfavourable times of the day (the circadian factor)

•Being short of sleep before starting work and/or prolonged prior wakefulness (the homeostatic factor) and

•Task-related factors (the physical and mental task demands).

Shift working in pre-hospital emergency care can cause disturbances in people’s natural sleep–wake cycles and disrupt circadian rhythms. Shift-workers typically accrue a sleep debt as sleep is reduced in both quantity and quality and sequential night shifts compound risk. Therefore, it is not surprising that pre-hospital care providers consistently describe high levels of fatigue. Job cycles can be lengthy and can increase fatigue, even when people are well-rested prior to a mission. Shift-work and fatigue carry a significant psychological morbidity.

Secondary stressors

There are many secondary stressors in addition to primary stressors experienced by PHEM practitioners whether trainees or established trained practitioners. The Team found that secondary stressors are prominent in pre-hospital emergency work—see Table 2.

Table 2 Examples of secondary stressors reported by PHEM traineesMoral distress and moral injury

The concept of moral distress was outlined by Jameton in 1984 [28]. It refers to the effects of knowing what should be done for a patient but being unable to do so because of situational and organisational constraints including lack of time, staff or equipment.

Moral injury has been described as the betrayal of what is right by someone who holds legitimate authority, in a high stakes situation [29], and as the result of: ‘perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs or expectations’ [30].

After morally injurious events, the experiences tend to revolve around shame and guilt, with concomitant withdrawal from social networks and isolation. Cognitive models of PTSD conceptualise symptoms as the result of the interactions of the mind with extreme fear in which the sufferer appraises the world as an unsafe place in which terrible things can happen. By contrast, the concept of moral injury suggests that the mechanism of action might be more closely related to feelings and thoughts about shame and guilt, that is, the world is a wrong place, in which terrible things are allowed to happen. Researchers believe that the guilt and shame tend not to reduce over time unless emotions are effectively processed [30, 31].

PHEM has a strong tradition of regular debriefing, flat hierarchies and teamwork, which may go some way to mitigating the effects of moral distress and moral injury, as does good leadership. The distress, dysfunction and disorders that staff experience are similar to the conditions that affect survivors of incidents and emergencies. Staff who experience distress that persists for more than two weeks require assessment.

Caring responsibilities and parental leave

Although less than full time training has become more established, arranging childcare around long shifts, at antisocial hours, and with unpredictable finish times can be sources of significant stress and fatigue.

Burnout

The systematic literature review showed that the most used scale was the Maslach Burnout Inventory [32]. Burnout is not a medical condition but a syndrome of chronic workplace stress and reflects a process that runs from high expectation and idealism to irreversible loss of interest and personal breakdown’ [32]. A recent guide describes burnout as ‘a state of physical and emotional exhaustion due to excessive and prolonged interpersonal work-related stressors’ [33]. It has three dimensions: emotional exhaustion; depersonalisation or cynicism; and reduced professional efficacy [34]. Distress, fatigue and moral distress that are experienced over substantial periods by practitioners plainly create risks of their becoming burned out.

Responding to the needs of practitionersInitial responses to staff who are distressed or at risk of being adversely affected by their exposure to emergencies

It is important to recognise that stress and distress are common reactions and not usually indicative of pathology though they may accompany mental health disorders. That is probably because working in small teams over long shifts provides the opportunity for natural conversations and peer support. It is important to develop a culture in which people feel valued and safe and can form helpful relationships with their colleagues. This emphasises the importance of having psychosocially-informed conversations embedded within organisations’ cultures.

Most pre-hospital emergency organisations care about employees’ wellbeing and are supportive. Many have rigorous governance processes in which cases are scrutinised in a systematic way. This often involves a technical debrief and discussion of cases in detail and is often highly valued education. However this type of reflection can create situations in which clinicians are expected to recount events and to re-live difficult or distressing events in front of peers, colleagues and supervisors. There is evidence that ‘debriefing’ of this nature has the potential to cause harm and that it should be avoided. Therefore, it is important to understand and select cases for open peer review sensitively. The UK’s National Institute for Health and Care Excellence (NICE) states that psychologically focused debriefing should not be offered for preventing or treating PTSD [35]. However, this is hugely different to teams sensitively offering mutual support and conducting emotional discussions. The Team’s experience while conducting the review was that many PHEM teams handle this sensitively and constructively. This process is described in a recent resource as an Operational Debrief conducted within the responding team in which opportunities may be taken to emotionally support members [36]. Research has shown that the three items covered next aid this approach [6,7,8]. Recommendations in a recent book and papers offer further support for the approaches recommended here [37,38,39,40,41,42,43,44].

Validation

People who are affected by emergencies and incidents regard social and professional acknowledgement of their experiences as key to their recovery. This process is called validation and describes recognition or affirmation of distress. Often colleagues and family members are the most important sources of validation. Validation by a professional person confers positive connotations on a person’s distress, their wish to seek support and may establish entitlement to care offered by a person perceived to have particular knowledge of the psychosocial impacts of major events. Validation challenges negative self-evaluation. Research on the Manchester Arena bombing has confirmed it as an important component of the initial approach to supporting people whether survivors or responders [5,6,7,8].

Listening

Active listening (making a conscious and trained effort to hear not only words but the complete message being communicated) is core to helping to support the wellbeing of colleagues.

Leadership

Leaders have a core role in addressing the impacts of stress on the workforce of their organisations. They should also be mindful of their own needs because responsibilities for other people are acknowledged to bring additional stress. Leaders should create a culture of safety, both from systems (aviation and clinical in PHEM) but also emotionally (it is okay to speak up, and admit fears, weaknesses, errors, and uncertainty and to express emotion). There is evidence that creating a culture of psychological safety reduces errors [45]. Leaders should also be familiar with key concepts relating to psychosocial care and shaping the culture of teams and environments so that teams are psychosocially informed and safe. Leaders should lead by example (e.g., by sharing learning from mistakes they have made and being open about their weaknesses). Organisations have a responsibility to ensure that staff can access support when they are concerned about their wellbeing.

A programme for support and care based on 15 key approaches

Healthcare staff who work in pre-hospital environments are required to do demanding and skilful work in hazardous environments. They are exposed to extraordinary events and may witness suffering, distress and death, with unusually high frequency. Inevitably, some of the impacts are stressful. The Team concluded that there are 15 key approaches for all organisations in their care for the wellbeing, psychosocial and mental health needs of their PHEM staff that are summarised in Table 3. There is more detail on the activities that assist staff in the Additional file 1.

Table 3 15 key approaches for organisations that employ PHEM practitionersA practical commentary on the key approaches

Pre-Hospital Employers Should Reduce Primary and Secondary Stressors.

The effect of primary stressors, which tend to receive the greatest attention in practice and research, may be reduced by adequate preparation, training and supervision. However, experience and research show that secondary stressors are not only potent but also frequent and often amenable to improvement.

Although primary stressors are very powerful in pre-hospital working environments, there are also many sources of secondary stressors. There may be a tendency to consider them of lesser importance but that would be a serious error because secondary stressors may be more impactful causes of problems for staff and an active plan is required to remove them or mitigate their effects. Employing organisations should take steps to identify and mitigate the secondary stressors experienced by their staff.

The Resuscitation UK Resuscitation Council UK (RCUK) considers it a duty to prepare all responders for the possible negative impact of a resuscitation event on their mental health and wellbeing [36]. It offers a video, an online resource for all responders and makes recommendations about a post-resuscitation procedure. In similar terms, an online teaching programme for Blue Light Services identifies how the principles in this paper might be put into effect (available at: mindedhub.org.uk/media/quvlpqkv/minded_brochure_a4_r6.pdf) [47].

Cohesion and leadership are vital to good care of staff

There is copious research to support conclusions that working in well-led, coherent teams is an important contribution to getting right the culture of health and social care organisations and is likely to offer strong protection for the staff wellbeing. This means being clear about: the nature of leadership that is required; the importance of being offered a buddy or mentor; access to a place and person to which staff can go if they are stressed; and the importance of supporting peer groups.

Often, the problems that affect staff of PHEM services are not indications that staff have developed or are developing mental disorders. This reveals the problem with terminology and the huge potential for misunderstandings about the meaning of terms such as welfare, wellbeing, psychosocial care, and mental healthcare. This confusion contributes to people’s reluctance to accept support and to stigma.

We recommend that the main firstline approach to caring for staff should be non-medical, which should be made readily available. Everyone should have access to facilities that are able to support staff in flourishing and gaining satisfaction and positive experiences from their work. A number of staff may be distressed by their experiences at work or the conditions in which they work.

However, a small proportion of staff may develop mental health problems of more serious natures that may require evidence-based, specialist assessment and treatment. There should be no complacency about this, and the non-medical and non-specialised facilities that offer psychosocial care should be capable of signposting of people in need to more specialised services as early as possible usually through occupational health services or primary care. It is only when staff are thought to need mental healthcare for a diagnosable disorder that their circumstances should be medicalised.

A stepped approach to care of staff

Increasing numbers of papers make recommendations for how employers should organise the responses to the needs of their employees including those who deliver PHEM [2, 11, 13, 48]. The authors’ opinion is that this should consist of: a universal wellbeing agenda for everyone; focused psychosocial care for those people who are struggling and/or distressed that can be used without formal referral; and agreed pathways for people who need, or appear to need specialist mental healthcare. Based on the Stevenson/Farmer review of mental health [19], the Team recommends that employers foster and support good mental health by attending to the three challenges covered in Table 4 [5].

Table 4 The three challengesStrategic underpinning for a stepped programme of care for PHEM staff

Table 5 summarises a number of actions that employers should take in order to underpin the approach recommended in this paper.

Table 5 Actions to support their strategy that employers should consider include