Originally submitted to Yorkville University, 2022
This is a mixed methods literature review exploring PTSD and burnout in paramedics. The 12 mandatory references are either quantitative (6) or qualitative (6). All studies are peer-reviewed and are supplemented with additional studies and professional literature from trade publications.
Background
Pre-hospital emergency care by paramedics is not only dynamic, but its inherent complexities have been shown to increase incidence of psychosocial risk factors, including Post-traumatic Stress Disorder (PTSD) and Occupational Burnout Syndrome (OBS). There is a gap in the research studying the paramedic perspective of human and organizational factors along with the innate nature of paramedicine and together, their cumulative impact on work-related distress [2,9,12,15, 16].
Problem Statement
The purpose of this literature review is to explore the types of pre-hospital stressors, risk factors and trauma identified by paramedics, the impact of said trauma on their mental health and well-being, and their preferred coping strategies [6,7]. The cumulative effects of ongoing exposure to stressful events can impact mental health, contributing to absenteeism and precipitate PTSD and OBS diagnosis [5,20].
Synthesis of this data will help inform mental health professionals regarding the prevalence of mental disorders amongst paramedics, common triggers and the impact of critical incident stress management supports and preferred coping strategies, from the self-reported perspective of the paramedics [16].
Literature Review
PTSD is defined by exposure to threatened death, serious injury or sexual violence to the extent that the individual experiences intrusion symptoms, dissociative reactions, psychological distress in response to symbolizing cues, stimuli avoidance, negative mood and cognition alterations, and alterations in arousal and reactivity to variables related to the stressful event [3]. Current research suggests that PTSD can also be secondary to stressful everyday events, including relationships; both social and work related, as well as prolonged illness [13].
OBS is not a unique DSM-5-Tr diagnosis, however, it can fall under the category of Occupational Problems: Other Problems Related to Employment. This includes the actual work, environment, unemployment, or threat thereof, job dissatisfaction, scheduling, harassment, interpersonal discord, and other psychosocial stressors [3]. In a three-dimensional model, it is comprised of overwhelming exhaustion, a sense of ineffectiveness and cynical attitudes coupled with feelings of detachment from a job or situation. There is some movement to redefine burnout as exhaustion and ongoing research is exploring the link between burnout and diagnosed mental illness [10].
Paramedicine is ever evolving, the scope of practice is demanding, and societal, organizational, and moral burdens in a system that is overwhelmed, have all been established as contributing factors to paramedic PTSD and OBS [1,11,19].
Primary Topic. What is the role of PTSD (post-traumatic stress disorder) in paramedic burnout?
Current Knowledge: PTSD is often comorbid with depression, anxiety, mental exhaustion, and sleep disorder [10,13,14,18,19]. Current literature identifies traumatic events, such as accidents, violence (both as a responder and as a victim of), and threat to life [2,4,5,6,7,11,13,18] as key contributors to PTSD. However, as literature in the field is expanding, social and organizational stressors are also being highlighted, and include shift length [4], ambulance ramping [1,19], patient transfer services [7,12], work environments; both in the field and within the organizational structure [15], and the evolution of paramedic roles and responsibilities [1]. At the same time, all these factors are under the ongoing scrutiny of the public, increasing pressure on paramedics and their performance [11].
Given the demands on the North American health care system, paramedics are also subject to the risk of moral injury. Historically, paramedics were trained to respond to an emergency, stabilize and transport a patient to hospital. With increasing attrition, shortages in staffing and resources, and increased offload delays, paramedics are routinely trapped in hospital hallways and unable to respond to Code 1 emergency calls. The psychological toll this takes on paramedics is referred to as moral suffering and is a contributing factor to both PTSD and OBS [19].
Kinds of Studies Available: Although several studies mention that the availability of subject literature is limited, there is a variety of quantitative, qualitative, systemic, case study, mixed-methods, and meta-analysis available.
Methodology Being Used: Quantitative studies in the field are primarily survey, questionnaire or checklist-based, whereas qualitative studies are usually grounded theory or phenomenological and often utilize recorded interviews, anecdotal online postings, or trauma narratives for data collection.
Synthesized Results: Results of PTSD triggers contributing to paramedic burnout are catalogued in Tables 1 and 2. Table 1 reflects multiple research projects focused on physical and work specific stressors. These numbers are much more robust than those illustrating the more subjective measures of Table 2.
Table 1
Professional triggers for PTSD and OBS
| Physical Exposure | Work Environment | Organizational Structure |
| -car accidents [2,11,18] -death of a patient [2,11,16,18] -violence [2,5,11,16,18] -vulnerable patients/victims [2,11,12,16] -pediatric patients [2,5,11,12] -repeated trauma exposure [2,4,5,6,7,11,12,13,14,16,18,20] -personal injury [4,5,7,11] -emergency vehicle accidents [4] -critical incidents [5,6,7,11,15,18] -mass causality incidents [5] -exposure to illness [7,12] -patient handling injury [7] | – primary care collaboration deficits [1,8,13,19] -long hours [2,11,13,19] -young colleagues [4] -inexperienced partners [4] -shift work [4,5,8,14] -hunger/nutritional deficits [4,13] -lack of sleep [4] -call volume [4,11,13] -aggression/assault by patients [6,7,10,13,17] -unpredictable [8,14] -lack of resources [11,13,19] | -lack of (standardized) training [1,2,11] -inconsistent clinical practice guideline (CPG) communication [2,15] -community programs slow to meet population needs [1,11] -fear of job loss [2] -hierarchical supervision [8] -lack of recognition [8,11] -short staffed [11] -strict supervisory policies [10,11] -favouritism by supervisors [11] -policy set by those not trained in the field [11] |
Table 2
Interpersonal, social, and psychological triggers for PTSD and OBS
| Interpersonal | Social | Psychological |
| -conflict with patient families [2] -colleague irritability [2] -breakdown of marriage/family [4] -taking work home [4] | -understanding the role of community paramedics [1] -underappreciation [2] -stigma [6] | -fear of personal injury [4,5,13] -pressure of being watched [2,13] -disillusionment with job [6,9,13] -fear of stigma [6] -moral injury [11,13,19] |
Table 3
Observed outcomes of PTSD and burnout in paramedics
| Personal | Professional | Psychological | Physiological |
| -increased divorce rates [4] -decreased social engagement [4,11] | -absenteeism [4,5,11,19] -lower quality of care [5] -high turnover rates [4,5,19] -detachment from the job [9] -avoidance [10] -decision making [14] -situational awareness [14] -problem solving abilities [14] | -increased suicidal ideation [4,9,12,13,19] -increased incidence of suicide [4,9,12,19] -irritability [4,11,13] -emotional changes [4,11,13,20] -moral injury [12,14] | -fatigue [4,12,14,19] -cardiovascular disease [4,13] -gastrointestinal conditions [4,13] -sleep disturbances [5,7,20] -anxiety [9,14,18,19,20] -depression [2,9,10,12,13,14,18,19,20] -intrusion/re-experience [11,12,13,20] -autonomic hyperstimulation to trigger [11,13,20] |
Research Integrity: Research integrity was established with appropriate ethics committee and Institutional Review Board [8] approvals and the use of peer-reviewed and gold standard questionnaires and surveys for quantitative studies. Many of the qualitative interviews were semi-structured and based on questions that had been piloted and refined, establishing face and construct validity. Studies demonstrated purposiveness and congruence with the stated hypotheses. Several studies recorded interviews, and all were audited to ensure accuracy of translation, transcription, and inter-rater reliability. Quantitative data was validated using regression analysis. All participants were voluntarily recruited and provided informed consent. Participants were assured of the confidentiality of their answers and their right to terminate participation [8]. Some studies also provided follow-up to ensure mental wellness after addressing such sensitive topics [2,6].
How the Research Enhances the Current Knowledge Base: All data and opportunities to glean add invaluable robustness to available literature. The quantitative data provided a clear correlation between paramedics, PTSD, and burnout. Further factor analysis would prioritize treatment and organizational structure needs. The interviews and trauma narratives allowed researchers more insight into paramedics’ perceptions of events and situations precipitating these diagnoses.
Flaws & Biases: The use of audio-recorders in interviews has been challenged as introducing social desirability and fear of reprisal biases. Conversely, audio-recording of interviews preserves the accuracy of what was said and aids in the reduction/elimination of transcription error or bias [17]. Memory bias was also mentioned in that time since the event, rehearsal and perspective could have skewed recollection of events [11]. Samples were based on purposive criteria and voluntary participation and may have confounded results as those paramedics unwilling to participate due to existing biases, mental illnesses, or fear of reprisal would not have been represented, thus risking self-selection bias [2,8]. Other confounds may include past experiences, past/concurrent counselling, discrimination, support networks, organizational structures, and interpersonal work relationships.
Gaps In the Body of Research: Very few studies compared paramedic experiences or organizational structure cross-culturally. Further study on gender differences, career vs volunteer and urban vs rural settings would help refine the understanding of a broader sample and make the data more generalizable [7,8,11].
Secondary Topic. How does the clinical environment affect the coping strategies of paramedics?
Current Knowledge: Across the literature, trends in coping mechanisms have been similar and include Critical Incident Stress Management [16]. Paramedics are often constrained from speaking about their struggles with mental injury and illness due to stigma [2,5,6,7,9,11,13,14,15,16,19,20].
How the Research Enhances the Current Knowledge Base: Cultural differences in coping strategies suggest that there is work to be done in acknowledging PTSD and OBS, overcoming stigma and reprisals, and normalizing informal and professional supports [11].
Flaws & Biases: Data overall may have been tainted by self-report biases [8]. There was little information about specific organizational models, the differences in rates of PTSD or OBS in varying demographics, and the supports and resources available or provided by paramedic organizations.
Gaps In the Body of Research: Although some of the literature mentioned destructive behaviours such as drinking, gambling and breakdown of the family [10,11], there was no correlative data to demonstrate causality [8].
Summary
After reviewing the literature, I would amend my title to be, “PTSD and OBS in paramedics and factors affecting coping strategies.” Although there were inferences that PTSD contributed to paramedic fatigue and burnout, there were no studies demonstrating explicit correlation. The scope of literature provides a cursory overview of PTSD and the traumatic nature of paramedic responsibilities, but there is not a broad spectrum of research that explores contributing factors on a deeper level.
Both qualitative and quantitative research were available, however the most meaningful for this review were the qualitative interviews and trauma narratives, as they provided greater insight into the paramedic perspective than did surveys or Likert Scales [8].
Implications
Unanimously, the literature identified the elevated risk of PTSD and OBS in paramedics, due to the traumatic, physical, and emotionally stressful nature of the work. Paramedic feedback indicated a preference to seek confidential, professional counselling over peer support. When considering programs like CISM (Critical Incident Stress Management) [5,16] and peer support programs [9], this literature supported organizationally provided professional counsellors.
Stigma was seen to be a deterrent in seeking support after a traumatic incident [2,5,6] and it is incumbent on organizations to normalize asking for help without penalty. Some EHS (Emergency Health Services) have peer support teams that follow up with paramedics post incident, however those calls may come while the paramedic is still working and even while they are on another call [15].
Ongoing assessment of mental wellness and burnout could aid in the mitigation of EHS staffing decline and the rise of short- and long-term disability due to PTSD and OBS [6].
Ideas for Future Research
Research dedicated to the human factors affecting paramedic PTSD and OBS as well as further exploration of organizational structure would provide perspicacity into variables that could be managed to alleviate some of the burden on paramedics. Cross-cultural research would be beneficial to highlight EHS systems that are thriving and help identify what is different from those struggling with retention and high levels of PTSD and OBS.
An exploration of when paramedics would be most likely to seek counselling and what, specifically, would prevent them from doing so, would enhance development and refinement of CISM and peer support programs [15].
Conclusion
Both quantitative and qualitative measures were used in this literature review. Gold standard surveys, questionnaires, and self-reports [5,10,12,15,17,20] provided concrete data to establish PTSD and OBS. Phenomenological semi-structured interviews [2,11,14], trauma narratives [6], and Grounded Theory research [19] provided qualitative data.
Paramedics reported trauma, pediatric and vulnerable persons emergencies, violence (against the public and themselves), interpersonal stressors and organizational factors (macro: structure and micro: equipment) as the primary contributors to PTSD and OBS.
Paramedics identified fear of stigma and reprisal as reasons to not pursue therapy but also indicated that they were more likely to pursue confidential professional counselling over discussing their mental wellness with their cohorts.
Sampling bias may have contributed to reduced validity, as all respondents were voluntary and participation invitations were distributed through employers. Gaps in the research include cross-cultural comparisons of mental wellness, psychosocial perceptions and organizational structures. There is also little research available on the role of gender in paramedic mental wellness. Organizational and psychosocial variables are difficult to control and may be more relevant than the current literature portrays. Further research into organizational models, both regional and cross-cultural, could provide invaluable insight.
References
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