Practical psychosocial care for providers of pre-hospital care: a summary of the report ‘valuing staff, valuing patients’

The literature has documented the poor self-reported mental health of emergency service workers in the UK [15, 16]. However the terminology is a challenge because the phrase ‘mental health’ has a wide variety of overlapping meanings and uses. The term ‘mental health problems’ is used often but is imprecise; defining the terms used is important if we are to compare research results and offer the most appropriate forms of care. The terms used here and in the Additional file 1 are those in the glossary to the Team’s report. [10]

In 2017, the Stevenson/Farmer review of mental health and employers reported that the human cost of mental health problems is huge, highlights higher rates of poor mental health and suicide for employees in healthcare services and recommends fostering and supporting good mental health in workplaces [19]. NHS Employers reported that, compared to people working in other professions, doctors are twice as likely and nurses are four times as likely to take their own lives to kill themselves [15].

The Stephenson/Farmer review identifies three broad groups of staff (Fig. 1) and considers how employees might be better supported.

By inference, the report presents three main challenges to employers and they are:

This advice resonates with our use of terminology and led to the Team agreeing the three interlinked objectives for caring for staff shown in Table 1 [5]

Research on survivors of the Manchester Arena bombing in 2017 shows just how important is support from families and support from other people involved in the same emergency to survivors’ early coping and recovery [6‐8]. Social support and contributing to community development, which are both parts of PFA, can accelerate survivors’ longer-term adaptation and recovery and aid prevention of their developing mental health disorders in the medium- and longer-terms. Evidence from UK research with family members of firefighters showed that families/relatives [20]:

Healthcare staff may be hesitant to discuss at home the details and emotional impact of their work in order to protect their families despite the evidence suggesting that families can help to alleviate worries by encouraging them to talk about their jobs and what they entail. Recently, we have seen recognition of the impact of the changes to work patterns created by the COVID-19 pandemic [5].

Emergency responders are a mix of people from several disciplines and agencies who have differing capabilities, roles and experiences. They face differing profiles of psychosocial risk and needs for education, training, and social and peer support. Most pre-hospital workers in the UK are employed by ambulance services. A smaller group of clinicians, which includes nurses, paramedics and doctors, work in highly specialised pre-hospital critical care units, and respond to high acuity incidents. These units are often well-resourced and surveys have emphasised the positive aspects of this working environment.

PHEM practitioners are exposed to, and witness suffering, distress, and death, with unusually high frequency and are under particular pressure due to the increased and increasing demand on their services. These factors are known as primary stressors. They are the sources of worry, anxiety or pressure that stem directly from the events and consequential tasks that the staff face in delivering high-quality care for patients. They may reflect single events but, more often, are an accumulation of pressure over time. Research suggests that levels and duration of exposure are a major risk factor for people who develop mental health problems, such as symptoms of PTSD [21], and this isoften referred to as ‘the dose effect’. Much more recently, academic studies of the impacts of being exposed to multiple adverse events have been published [22, 23]. The cumulative and interactive effects may persist over lengthy periods and challenge the habituation fallacy [24]. The clinical workloads experienced by PHEM practitioners may be challenging cognitively, emotionally, and psychosocially. However, presumptions of positive adaptation have allowed a myth, the Habituation Fallacy, to arise and the truth is that repeated exposure to severe adversity makes it harder, not easier, for disaster survivors to cope with a new negative event [24]. This is an additional reason for focusing on meeting the needs of staff who work in challenging environments and experience recurrent exposures to emergencies.

The work of PHEM practitioners is likely to be stressful by virtue not only of the enormity of other people’s suffering (primary stressors) but also the demands of performing demanding and skilful work in hostile environments. The latter pose secondary stressors. PHEM is an arena of specialist practice where potent primary and secondary stressors meet. The stress experienced in pre-hospital environments is influenced by social factors, life and work circumstances (including policies, practices, and social, organisational, and financial arrangements) and societal and organisational responses to an incident or emergency [25].

Research into children’s development suggests that ‘… long-term adverse outcomes are better predicted by the total number rather than the specific nature of environmental risk exposures’ [26]. We think this applies to adults too. Secondary stressors and adverse outcomes can be modified by the adequacy and effectiveness of employers’ responses to events and expectations of employees’ performance, career aspirations, and concerns of staff about their training, the conditions in which they work and live and their work-life balance. Secondary stressors can persist for longer than most emergencies and can limit recovery and adaptation. The work that underpins this paper has suggested that secondary stressors have a greater potential to affect pre-hospital workers than do primary stressors and the matters raised by staff who seek support frequently concern secondary stressors.

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 [5‐8].

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

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.

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.

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.

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.

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 [6‐8]. Recommendations in a recent book and papers offer further support for the approaches recommended here [37‐44].

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.

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].