Dynamic psychosocial risk and protective factors associated with mental health in Emergency Medical Service (EMS) personnel

A Qualitative Analysis of Barriers to Evidence-Based Care in the Prehospital Management of Patients with Suspected Acute Coronary Syndrome

OBJECTIVES

Prehospital electrocardiogram (ECG) and administration of aspirin are evidence-based strategies for patients with acute coronary syndrome (ACS). However, emergency medical services (EMS) compliance in patients with suspected ACS varies widely. We sought to understand the barriers to prehospital ECG acquisition and aspirin administration for patients with suspected ACS.

METHODS

In this qualitative study, we interviewed EMS clinicians at three geographically diverse United States (U.S.)-based EMS agencies. We interviewed practicing clinicians and quality and operations leaders at these agencies. Based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, interviews were recorded, transcribed, and analyzed using a grounded qualitative approach with open coding. The Systems Engineering Initiative for Patient Safety (SEIPS) framework and a constant comparison technique were used to identify and refine themes.

RESULTS

Twenty-five paramedics and 20 additional agency personnel participated. Median age was 41 (IQR: 34-51) years and 13 (29%) were female. Themes were organized using SEIPS and longitudinally through four phases of an EMS call. During the pre-arrival phase, staffing challenges, training quality, and dispatch may anchor EMS clinicians on a diagnosis. During the diagnosis and treatment phase, safety and communication barriers may take priority over care delivery. Additionally, EMS clinicians must allocate assets (e.g. whether to send an advanced life support unit) and financial resources; veteran EMS clinicians identified their experience whereas newer clinicians cited their recent education when making these decisions. Also, diagnostic uncertainty due to increasing patient complexity and atypical presentations contributed to diagnostic errors. During the response and transport phase, the scope of practice limits the use and interpretation of the ECG, with clinicians reporting that liberal use of ECG led to more rapid decision-making. Finally, in the after phase, personnel reported the "psychologically taxing" nature of the job contributing to biases, bad habits, and burnout. Performance feedback was desired for personal development, though currently perceived as infrequent and punitive.

CONCLUSIONS

Multiple, interrelated themes underscored the complexities of delivering evidence-based care to prehospital patients with ACS. Education in ECG interpretation, resource allocation, bias, and enhancing feedback may serve as strategies to address the identified barriers.

Understanding the Role of Empathy and Gender on EMS Clinician Occupational Stress and Mental Health Outcomes

BACKGROUND

Emergency Medical Service (EMS) clinicians experience high levels of occupational stress due to long hours, short staffing, and patient deaths, among other factors. While gender has been partially examined, little is known regarding the role of empathy on occupational stress and mental health (MH) outcomes among EMS clinicians. Therefore, the current study examines the moderating role of empathy and, separately, gender on associations between occupational stress and mental health.

METHODS

A cross-sectional examination of EMS clinician occupational and personal wellbeing was conducted via an anonymous, electronic survey. Information on clinician demographics, and validated measures of occupational stress, burnout, and MH outcomes were collected. Empathy was assessed using the Toronto Empathy Scale (TEQ). Descriptive/bivariate statistics were conducted for variables of interest. Separate multivariable regression models evaluated associations between occupational stress and mental health outcomes. Empathy and gender were examined as potential moderators using interactions.

RESULTS

A total of 568 EMS clinicians completed the survey. High levels of mental health difficulties were reported (34.0% anxiety, 29.2% depression, 48.6% burnout). Increased occupational stress was associated with increased anxiety (OR =1.08, 95% CI 1.05-1.10), depression (OR = 1.09, 95% CI 1.06-1.10), and burnout (OR = 1.10, 95% CI 1.07-1.12). No moderation analyses were significant. Greater resilience was associated with lower depression, anxiety, and burnout.

CONCLUSION

EMS clinicians, much like other first responders, experience considerable occupational stress, of which is associated with mental health difficulties and burnout. Findings underscore the need for intervention programs aimed at reducing the impact of occupational stress and the promotion of resilience. Continuing to understand the full scope of EMS mental health, including the role of resilience, is imperative, particularly in light of future public emergencies.

Psychosocial Work Stress and Occupational Stressors in Emergency Medical Services

Emergency medical service (EMS) professionals often experience work stress, which escalated during COVID-19. High job demand in the EMS profession may lead to progressive decline in physical and mental health. We investigated the prevalence of psychosocial job stress in the three levels of EMS: basic, advanced, and paramedic, before and during the COVID-19 pandemic. EMS professionals (n = 36) were recruited from EMS agencies following the Institutional Review Board approval. Participants took surveys on demographics, personal characteristics, chronic diseases, and work schedules. Job stress indicators, namely the effort–reward ratio (ERR) and overcommitment (OC), were evaluated from survey questionnaires using the effort–reward imbalance model. Associations of job stress indicators with age, sex, body mass index, and working conditions were measured by logistic regression. Psychosocial work stress was prevalent with effort reward ratio > 1 in 83% of participants and overcommitment scores > 13 in 89% of participants. Age, body mass index, and work hours showed strong associations with ERR and OC scores. The investigation findings suggested that a psychosocial work environment is prevalent among EMS, as revealed by high ERR, OC, and their correlation with sleep apnea in rotating shift employees. Appropriate interventions may be helpful in reducing psychosocial work stress in EMS professionals.

No Two Systems Are the Same: Paramedic Perceptions of Contemporary System Performance Using Prehospital Quality Indicators

Introduction In recent years, researchers have identified two new models of paramedicine within the Anglo-American paramedic system known as the Directive and Professionally Autonomous paramedic systems. The research team now seek to compare paramedic perception of system performance between the two systems using prehospital quality indicators. Methods Paramedics employed within Anglo-American paramedic systems undertook a survey evaluating their experience and perception of system performance against a set of modified prehospital quality indicators. Data were collected using a survey combining single-choice questions with matrix multiple-choice questions. Key results were cross-tabulated with demographic (informant) and system factors to compare performance between the two new paramedic systems. Results The survey indicated a substantial difference in perceived clinical and operational performance between the Professionally Autonomous and Directive paramedic systems, with the Professionally Autonomous paramedic system performing consistently better in all 11 prehospital quality indicator domains. Conclusion The results of this survey are a vital step in helping paramedics, health leaders, and academics understand the complex relationship between paramedic system design and system performance, and, for the first time, provides empirical evidence upon which to make a conscious decision to adopt one system or the other.

Sleep and day-to-day PTSD symptom variability: an ecological momentary assessment and actigraphy monitored study in trauma-exposed young adults

BACKGROUND

Disrupted sleep and post-traumatic stress disorder (PTSD) are bi-directionally linked and have been found to mutually reinforce each other on a day-to-day basis. However, most of the previous research has focused on subjective measures of sleep only.

OBJECTIVE

Here, we investigated the temporal relationship between sleep and PTSD symptoms using both subjective (sleep diary) and objective measures of sleep (actigraphy).

METHODS

Forty-one non-treatment seeking, trauma exposed young adults (age M = 24.68, SD = 8.15) with a range of PTSD symptom severities (PTSS, 0-53 on PCL-5) were recruited. Participants completed two surveys per day over four weeks to measure day-time PTSD symptoms (i.e. PTSS and number of intrusions) and night-time sleep subjectively, while wearing an actigraphy watch to measure sleep objectively.

RESULTS

Linear mixed models revealed that subjectively reported sleep disruptions were associated with elevated next-day PTSS and increasing number of intrusive memories both within and between participants. Similar results were found for daytime PTSD symptoms on night-time sleep. However, these associations were not found using objective sleep data. Exploratory moderator analyses including sex (male vs. female) found that these associations differed in strength between sexes but were generally in the same direction.

DISCUSSION

These results were in line with our hypothesis with regards to the sleep diary (subjective sleep), but not actigraphy (objective sleep). Several factors which have implications on both PTSD and sleep, such as the COVID-19 pandemic and/ or sleep-state misperception, may be potential reasons behind those discrepancies. However, this study had limited power and needs to be replicated in larger samples. Nonetheless, these results add to the current literature about the bi-directional relationship between sleep and PTSD and have clinical implications for treatment strategies.

Work climate in emergency health services during COVID-19 pandemic-An international multicenter study

Introduction

A good working climate increases the chances of adequate care. The employees of Emergency in Hospitals are particularly exposed to work-related stress. Support from management is very important in order to avoid stressful situations and conflicts that are not conducive to good work organization. The aim of the study was to assess the work climate of Emergency Health Services during COVID-19 Pandemic using the Abridged Version of the Work Climate Scale in Emergency Health Services.

Design

A prospective descriptive international study was conducted.

Methods

The 24-item Abridged Version of the Work Climate Scale in Emergency Health Services was used for the study. The questionnaire was posted on the internet portal of scientific societies. In the study participated 217 women (74.5%) and 74 men (25.4%). The age of the respondents ranged from 23 to 60 years (SD = 8.62). Among the re-spondents, the largest group were Emergency technicians (85.57%), followed by nurses (9.62%), doctors (2.75%) and Service assistants (2.06%). The study was conducted in 14 countries.

Results

The study of the climate at work shows that countries have different priorities at work, but not all of them. By answering the research questions one by one, we can say that the average climate score at work was 33.41 min 27.0 and max 36.0 (SD = 1.52).

Conclusion

The working climate depends on many factors such as interpersonal relationships, remuneration or the will to achieve the same selector. In the absence of any of the elements, a proper working climate is not possible.

Analysis of Work Related Factors, Behavior, Well-Being Outcome, and Job Satisfaction of Workers of Emergency Medical Service: A Systematic Review

Background: The workloads of emergency medical service personnel (EMS) are varied. In the absence of recovery, health consequences can result. The aim of this review was to analyze the literature on the associations between psychosocial or physical work factors on one hand and the well-being outcomes and job satisfaction on the other hand. Methods: A systematic literature review examining the workloads, behavior, and well-being of EMS including emergency physicians, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement for the reporting systematic reviews, was performed. The PubMed, Ovid Medline, Cochrane Library, Scopus, Web of Science, PsycINFO, Psyndex, and Embase electronic databases were used. Results: Thirty-three studies were included. These were divided into studies that predominantly focused on the behavior (6), stress and strain (22), and well-being (5) of EMS. Only four studies also examined emergency physicians. The studies indicated a high prevalence of psychological and physical stress factors. Burnout and posttraumatic stress disorders have been the most studied consequences of mismatched stress. The health status variable performs better in conjunction with higher qualifications. Age is not a protective variable in some studies. Conclusions: EMS workloads are varied and must be assessed on an individual basis. Studies on emergency physicians are needed. Organizational and personal measures must become the focus of health promotion and prevention in the workplace.

Multilevel analysis of sleep quality and anger in emergency medical service workers

OBJECTIVE

Poor sleep quality characterizes the emergency medical service (EMS) profession. Anger is particularly affected by sleep disturbance and may be related to sleep quality at both between- and within-person levels, yet this has never been examined. The current study performed a multilevel analysis of the relationship between sleep quality and anger among EMS workers.

DESIGN

Ecological momentary assessment PARTICIPANTS: Seventy-nine EMS workers employed at an emergency medical service provider in Central New York.

MEASUREMENTS

Participants completed 8 daily assessments that inquired about sleep quality and anger.

RESULTS

EMS workers who typically experienced poorer sleep quality reported greater anger levels; for instance, workers who routinely experienced poor sleep quality reported anger levels that were 18%-35% higher compared to workers receiving fair sleep quality. Regardless of their typical sleep quality, days when workers experienced poorer sleep than usual was characterized by higher levels of anger: on a day when a worker experienced poorer sleep quality than usual for them, their anger levels were 5% higher on that day regardless of their typical sleep quality.

CONCLUSIONS

EMS workers regularly experiencing poor sleep quality experience more anger. However, even workers who typically have better sleep quality experience anger elevations following poor sleep. These findings suggest that interventions targeting both between- and within-person factors impacting sleep may be important for addressing sleep quality's influence on anger in the EMS profession.

The interplay between acute post-traumatic stress, depressive and anxiety symptoms on healthcare workers functioning during the COVID-19 emergency: A multicenter study comparing regions with increasing pandemic incidence

BACKGROUND

Healthcare workers (HCWs) deployed to the frontline during the COVID-19 pandemic are at risk for developing mental disorders, with a possible impact on their wellbeing and functioning. The present study aimed at investigating post-traumatic stress symptoms (PTSS), anxiety and depressive symptoms and their relationships with impairment in the functioning impairment among frontline HCWs from three Italian regions differently exposed to the first wave of the COVID-19 emergency: Tuscany (low), Emilia-Romagna (medium) and Lombardy (high).

METHODS

514 frontline HCWs were consecutively enrolled in hospital units devoted to the treatment of COVID-19 patients. They completed the IES-R, PHQ-9 and GAD-7 to assess PTSS, depressive and anxiety symptoms respectively, and the WSAS to investigate functioning impairment.

RESULTS

A total of 23.5% of HCWs reported severe PTSS, 22.4% moderate-severe anxiety symptoms, 19.3% moderate-severe depressive symptoms and 22.8% impairment in global functioning. HCWs from the higher-exposure regions reported significantly higher scores in all instruments than those from lower-exposure regions. In a multiple linear regression model, PTSS, depressive and anxiety symptoms presented a significant positive association with the functioning impairment. Both PTSS and depression resulted to be independently related to functioning impairment.

LIMITATIONS

The cross-sectional design and the use of self-report instruments.

CONCLUSIONS

Depressive and PTSS appear to be the greatest contributors to functioning impairment in HCWs exposed to a massive stressful sanitary event as the COVID-19 pandemic. A more accurate assessment of work-related mental health outcomes in such population could help planning effective prevention strategies and therapeutic interventions.

Prevalence of pain, analgesic self-medication and mental health in German pre-hospital emergency medical service personnel: a nationwide survey pilot-study

PURPOSE

The aim of this study was to estimate the prevalence of pain, the extent of analgesics intake and the mental health status of German pre-hospital emergency medical service (EMS) personnel.

METHODS

We conducted a nationwide online survey, which consisted of sociodemographic and job-related items, questions on pain and analgesics intake and the short-version of the validated Depression-Anxiety-Stress Scale (DASS-21).

RESULTS

A total of 774 EMS personnel with a mean age of 33.03 (standard error [SE] 0.37) years were included into the final analysis of which 23.77% were female. Pain was reported by 58.64% (454 of 774) of the study participants with 10.72% (95% confidence interval [CI] 8.54%; 13.29%) suffering from chronic, 1.68% (95% CI 0.89%; 2.87%) from acute and 46.25% (95% CI 41.49%; 51.30%) from recurrent pain, respectively. Most frequent location of pain was lumbar spine. Analgesics were used by 52.76% (239 of 454) of pre-hospital EMS personnel with pain (acute 76.92% / chronic 69.88% / recurrent 47.90%). Moreover, participants with chronic and recurrent pain indicated significantly higher depression (p ≤ 0.001), anxiety (p ≤ 0.001), and stress (p ≤ 0.001) levels compared to those without pain, respectively.

CONCLUSION

This study indicates a high prevalence of pain and analgesics usage in participating German pre-hospital EMS personnel and a poorer mental health in those with chronic and recurrent pain. Therefore, disease prevention and health promotion measures are needed to preserve health of pre-hospital EMS personnel.

Work Climate Scale in Emergency Services: Abridged Version

This study is based on a 40-item work climate scale in hospital emergency services (WCSHES). Teams working in these emergency services experience a heavy workload and have a limited amount of time with each patient. COVID-19 has further complicated these existing issues. Therefore, we believed it would be helpful to draft an abridged version of the 40-item WCSHES, considering both validity and reliability criteria, but giving greater weight to validity. One hundred and twenty-six workers between the ages of 20 to 64 (M = 32.45; standard deviation (SD = 9.73)) years old participated voluntarily in the study. The validity, reliability, and fit model were evaluated in an iterative process. The confirmatory factor analysis yielded appropriate global fit indices in the abridged 24-item version (Χ²(248) = 367.84; p < 0.01, RMSEA = 0.06 with an interval of 90% from 0.05 to 0.07, SRMR = 0.08, GFI = 0.9, AGFI = 0.96, CFI = 0.98, NFI = 0.95, and NNFI = 0.98), along with test criteria validity (ρ_XY = 0.68, p < 0.001) and excellent reliability (α = 0.94 and ω = 0.94), maintaining the same conceptualization and usefulness of the original scale. The abridged 24-item version was used to measure four work climate factors (work satisfaction, productivity/achievement of aims, interpersonal relations, and performance at work). Evidence of the usefulness of the new abridged scale is provided along with a description of our study limitations and future areas for development.