Organizational strategies to address posttraumatic stress injuries among Canadian paramedics

Abstract

BACKGROUND:

Paramedics are a high-risk occupational group for posttraumatic stress injuries (PTSI), and increasingly, evidence suggests that organizational factors play a significant role. While several resources for paramedic services to address PTSI exist, there is limited knowledge as to which PTSI-related programs and practices are implemented and how they are perceived in the workplace.

OBJECTIVES:

This research aimed to explore key informants’ perspectives on existing and desired organizational-wide initiatives for, as well as the challenges and potential solutions to, the primary prevention, early detection and intervention, and disability management of PTSI in Canadian paramedic services.

METHODS:

Semi-structured interviews were conducted with 12 key informants from jurisdictions across Canada who have over five years of work experience in prehospital care. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis.

RESULTS:

Eight recurrent organizational elements (themes) for addressing PTSI emerged: psychologically safe and healthy work culture; consistent supervisor support, mental health training and awareness, opportunities for recovery and maintaining resiliency, recognition of PTSI and its diverse risk factors, access to a variety of support initiatives for PTSI, communication during medical leave, and meaningful work accommodations.

CONCLUSIONS:

While organizational-wide initiatives were in place for the primary prevention, early detection and intervention, and disability management of PTSI, systemic challenges with coordination, resource allocation, and worker engagement were also identified. These challenges prevented paramedic services from optimally addressing PTSI in their workplace. Integrating considerations from the eight organizational elements to address PTSI into broader existing management systems may have merit in overcoming the systemic challenges.

Keywords

Emergency medical services mental health personnel management psychological stress risk management

1 Introduction

Paramedics are a high-risk occupational group for a range of mental health problems, including both clinically and non-clinically diagnosable conditions that interfere with daily functioning [1 –5]. In this article, this range of mental health problems are referred to as posttraumatic stress injuries (PTSI) [6, 7]. Inherent stressors to out-of-hospital emergency medical work is tending to medical calls; some can be stimulating and manageable, while others can be frustratingly non-urgent, or strenuous and distressing [8]. In addition, overtime, shiftwork, staff shortages, and limited job autonomy are common occupational stressors within the paramedic industry that can contribute to the development of PTSI [1 , 8–11]. Considering the numerous stressors, it is not surprising that the rates of PTSI among paramedics are two to three-fold higher than the general population, with the prevalence of general psychological distress, depression, anxiety, and posttraumatic symptoms being 27%, 15%, 15%, and 11%, respectively [2]. PTSI affects not only the individual but also their communities (i.e., friends, family, and coworkers), their work capacity, and ultimately their organization’s ability to provide responsive and quality care. In response to the elevated risks and rates of PTSI, several workers’ compensation boards across Canada now presumptuously consider some forms of PTSI, such as posttraumatic stress disorder (PTSD), to be work-related across first responder occupations [12]. In addition, increasing evidence suggests that organizational factors play a significant role in preventing and managing PTSI in the workplace and supports the development and implementation of organizational-wide strategies [5 , 13–19].

To help organizations address various states of health, many guidelines and resources have adopted the disease prevention model for intervention [15 , 20–23]. At its core, the model features three levels of interventions: primary prevention aimed at maintaining good health among healthy individuals (e.g., training and education); early detection and intervention aimed to identify and support individuals with early signs and symptoms of a disease or injury (e.g., peer support); and disability management aimed to support symptom management for those who are injured or ill (e.g., work accommodations) [21, 23]. The disease prevention model for intervention has previously been used as a framework for an environmental scan and a scoping review to identify and synthesize the grey and peer-reviewed literature, respectively, on PTSI-related programs and practices for each level of intervention [24, 25]. While there are several recommended programs and practices for paramedic services to address PTSI, there is limited knowledge as to which PTSI-related programs and practices are implemented and how they are perceived in the workplace. Therefore, the objective of this study was to build upon the existing knowledge of recommended initiatives to address PTSI and explore key informants’ perspectives on the existing and desired organizational-wide initiatives for, as well as the challenges and potential solutions to, the primary prevention, early detection and intervention, and disability management of PTSI in Canadian paramedic services.

2 Methods

Semi-structured interviews were conducted with key informants of the Canadian paramedic community. Key informant interviews are an effective qualitative method for quickly gathering relevant information and insights on a specific topic and can be used as a standalone research method [26]. For data analysis, the thematic analysis approach set out by Braun and Clarke was applied to identify, analyze, and report patterns in a structured and sequential manner [27, 28]. Ethical approval was obtained prior to the recruitment of participants.

2.1 Study participants

Key informants were defined as paramedics, supervisors, and union representatives who have over five years of experience working in the Canadian paramedic system. Purposeful sampling was used to select and recruit a diverse and information-rich sample [29]. Snowballing technique was also applied throughout the interview process to recruit additional key informants [30]. Recruitment and interviews were conducted between September 2019 and February 2020. Email invitations were sent to 30 potential participants, and 12 key informants returned signed consent forms agreeing to participate in a one-hour, audio-recorded, semi-structured interview. In total, five paramedics, five supervisors, and two union representatives participated; 25% of participants were female.

2.2 Data collection and thematic analysis

All interviews were conducted via teleconferencing on Zoom Version 3.6.5 (Zoom Video Com-munications, San Jose, California, USA) by the lead author using pre-developed interview guides tailored for each occupational group. The interview guides were designed to incorporate discussion surrounding the three levels of interventions within the disease prevention model for intervention [16]. In order to adopt the model for organizational contexts, interview questions related to disability management were split into 1) organizational initiatives to support individuals who require medical leave due a work debilitating PTSI, and 2) organizational initiatives to support those with a manageable PTSI and can return to or remain at work. The authors also acknowledge the significant involvement of workers’ compensation boards and the healthcare system in disability management; however, these systems were beyond the scope of this research unless they were explicitly related to how organizations coordinated with them. Figure 1 presents a visual summary of the operational framework that formed the interview questions. The interview guides were reviewed by a subject matter expert working in the paramedic industry to confirm relevancy and interpretation.

Fig. 1

Operational framework for exploring key informants’ perspectives on the existing and desired organizational-wide initiatives, as well as the challenges and potential solutions to addressing PTSI. Note: The workers’ compensation and healthcare systems operate in parallel with organizational initiatives to support individuals with PTSI; however, they are beyond the scope of this research.

Audio recordings of the interviews were transcribed using the speech recognition software Temi (REV.com Inc., San Francisco, California, USA) and reviewed by the participant for accuracy. The lead author then reviewed the transcripts and performed thematic analysis [27] using Microsoft Excel Version 2101 (Microsoft Corporation, Redmond, Washington, USA). Transcripts were first deductively coded into three categories (primary prevention, early detection and intervention, and disability management) based on the disease prevention model for intervention [16]. Within each category, recurring themes (organizational elements) to address PTSI in paramedic services were identified inductively; subthemes were also identified and coded when multiple concepts and perspectives emerged. All of the authors then reviewed and refined the emerging organizational elements to ensure that they represented the data in an organized and meaningful way. Quotes from the interviews were selected to summarize the findings. Where appropriate, participant responses were edited for minor typographic errors. Individual key informants are referred to by their occupational titles combined with a unique participant number.

3 Results

The average duration of the interviews was 97 (SD = 22) minutes. Thematic analysis revealed eight recurrent desired organizational elements for the primary prevention, early detection and intervention, and disability management of PTSI (Table 1). Key informants’ insights and perspectives of the current organizational initiatives, and challenges and recommendations to fulfill each of the elements are presented.

Table 1
Overview of key informants’ perspectives on desired and existing initiatives for, and the challenges to the primary prevention, early detection and intervention, and disability management of PTSI within the context of Canadian paramedic services

Organizational Elements and their Desired Characteristics Existing Initiatives Gaps and Barriers

Primary Prevention

Psychologically Safe and Healthy Work Culture Organizational culture recognizes that 1) PTSI is a legitimate injury; 2) PTSI is a normal outcome of exposure(s) to trauma; and 3) mental health supports should be used proactively and for treatment. •Mandatory mental health training provided to paramedics •Nature of the work requires a high level of resiliency

•Encouragement and reminders to use the mental health services available •Resistance to culture change

•Discouragement of stigmatizing comments (informal)

Consistent Supervisor Support Support is consistent and judgement-free; follow-up is provided. •Some organizations provided leadership with mental health training •Some supervisors felt/were inadequately trained to provide emotional support

•Some supervisors initiated support programs/ services for paramedics after a critical incident •Some supervisors questioned the criticalness of self-identified critical events

•Some supervisors monitored behavioural changes amongst staff and initiated check-ins when appropriate (informal) •Follow-up not provided after self-reported incidents

•Does not or cannot always grant downtime

Mental Health Training and Awareness Paramedics and their support systems (i.e., mental health professionals, peer supporters, supervisors, employee and family assistance programs (EFAP), and loved ones) are equipped with the knowledge, skills, and abilities to address PTSI and reduce stigma. •Mandatory mental health training provided to paramedics •Once trained, onus for addressing PTSI was put back onto paramedics

•Peer support received additional training •Training programs were not always tailored to the context of the paramedic environment

•Training for supervisors, mental health professionals, and EFAP have not been mandatory

Opportunities for Recovery and Maintaining Resiliency Work arrangements allow paramedics to take care of personal needs (i.e., meals and washroom) during a shift, rest and recover through regular sleep patterns, and engage in physical activity. •Establishment of health promotion and wellness committees •Limited training on strategies to manage organizational stressors and work-life balance

•Access to discounted fitness club memberships •Inadequately staffed to provide downtime

•Nature of the work makes it difficult to take care of personal needs

Early Detection and Intervention

Recognition of PTSI and its Diverse Risk Factors Events that commonly lead to PTSI, including chronic and cumulative exposures to trauma and suffering are detected. Mechanisms for self-identifying critical incidents and self-reporting of PTSI are established; barriers to self-reporting are minimized. •Some organizations had pre-defined a list of critical incidents •No system to track paramedics’ exposures to non-critical incidents and their personal triggers

•Critical incidents (as defined by the supervisor or organization) would initiate a check-in •‘Criticalness’ of an incident defer between individuals and personal triggers may be unknown beforehand

•Incident reporting mechanisms were available for paramedics to report self-identified critical incidents •PTSI may develop slowly over time and gradual changes may not be detected

•Supervisors monitored behavioural changes amongst staff and initiated check-ins when appropriate (informal)

Variety of Support Initiatives for PTSI Various supports are readily available and accessible to accommodate individual differences; barriers to accessing supports are minimized. •Time to defuse/ downtime: stress leave •Do not want to offload work to colleagues

•Support from coworkers: partners, colleagues, peer support, supervisors •Fear that shared information will reach management

•Mental health professionals: EFAP, (in-house) mental health professionals, mental health referral network, 24/7 distress lines, critical incident stress management •Limited mental health professionals with contextual knowledge of paramedic work and the occupational-specific stressors

•Financial supports: extended health benefits plan •Fear of losing livelihood security or career advancement opportunities

•Negative peer or personal experience

•Limited coverage for mental health services

•Contract workers may not qualify for benefits

Disability Management

Communications during Medical Leave Communications focus on paramedics’ well-being, and formalized training and organizational policies are provided. •Supervisors often deferred checking-in with paramedics on medical leave to human resources •Distrust of calls from the organization

•Supervisors have not been trained to conduct check-ins during a medical leave and there are no formalized procedures to do so

Meaningful Work Accommodations Paramedics are provided with opportunities to gradually return to the frontline or perform meaningful alternative duties with continuous follow-up. •Gradual return-to-work options: 3rd in car, reduced hours, reduced shifts, choice of partner/ mentorship program, avoiding peak times •Difficult to return to the place of trauma

•Alternative work options: administrative duties, community outreach/ public safety awareness programs, other projects at the organization •Not much work available and paramedics did not find administrative work to be meaningful

Organizational Elements and their Desired Characteristics	Existing Initiatives	Gaps and Barriers
Primary Prevention
Psychologically Safe and Healthy Work Culture Organizational culture recognizes that 1) PTSI is a legitimate injury; 2) PTSI is a normal outcome of exposure(s) to trauma; and 3) mental health supports should be used proactively and for treatment.	•Mandatory mental health training provided to paramedics	•Nature of the work requires a high level of resiliency
	•Encouragement and reminders to use the mental health services available	•Resistance to culture change
	•Discouragement of stigmatizing comments (informal)
Consistent Supervisor Support Support is consistent and judgement-free; follow-up is provided.	•Some organizations provided leadership with mental health training	•Some supervisors felt/were inadequately trained to provide emotional support
	•Some supervisors initiated support programs/ services for paramedics after a critical incident	•Some supervisors questioned the criticalness of self-identified critical events
	•Some supervisors monitored behavioural changes amongst staff and initiated check-ins when appropriate (informal)	•Follow-up not provided after self-reported incidents
		•Does not or cannot always grant downtime
Mental Health Training and Awareness Paramedics and their support systems (i.e., mental health professionals, peer supporters, supervisors, employee and family assistance programs (EFAP), and loved ones) are equipped with the knowledge, skills, and abilities to address PTSI and reduce stigma.	•Mandatory mental health training provided to paramedics	•Once trained, onus for addressing PTSI was put back onto paramedics
	•Peer support received additional training	•Training programs were not always tailored to the context of the paramedic environment
	•Training for supervisors, mental health professionals, and EFAP have not been mandatory
Opportunities for Recovery and Maintaining Resiliency Work arrangements allow paramedics to take care of personal needs (i.e., meals and washroom) during a shift, rest and recover through regular sleep patterns, and engage in physical activity.	•Establishment of health promotion and wellness committees	•Limited training on strategies to manage organizational stressors and work-life balance
	•Access to discounted fitness club memberships	•Inadequately staffed to provide downtime
		•Nature of the work makes it difficult to take care of personal needs
Early Detection and Intervention
Recognition of PTSI and its Diverse Risk Factors Events that commonly lead to PTSI, including chronic and cumulative exposures to trauma and suffering are detected. Mechanisms for self-identifying critical incidents and self-reporting of PTSI are established; barriers to self-reporting are minimized.	•Some organizations had pre-defined a list of critical incidents	•No system to track paramedics’ exposures to non-critical incidents and their personal triggers
	•Critical incidents (as defined by the supervisor or organization) would initiate a check-in	•‘Criticalness’ of an incident defer between individuals and personal triggers may be unknown beforehand
	•Incident reporting mechanisms were available for paramedics to report self-identified critical incidents	•PTSI may develop slowly over time and gradual changes may not be detected
	•Supervisors monitored behavioural changes amongst staff and initiated check-ins when appropriate (informal)
Variety of Support Initiatives for PTSI Various supports are readily available and accessible to accommodate individual differences; barriers to accessing supports are minimized.	•Time to defuse/ downtime: stress leave	•Do not want to offload work to colleagues
	•Support from coworkers: partners, colleagues, peer support, supervisors	•Fear that shared information will reach management
	•Mental health professionals: EFAP, (in-house) mental health professionals, mental health referral network, 24/7 distress lines, critical incident stress management	•Limited mental health professionals with contextual knowledge of paramedic work and the occupational-specific stressors
	•Financial supports: extended health benefits plan	•Fear of losing livelihood security or career advancement opportunities
		•Negative peer or personal experience
		•Limited coverage for mental health services
		•Contract workers may not qualify for benefits
Disability Management
Communications during Medical Leave Communications focus on paramedics’ well-being, and formalized training and organizational policies are provided.	•Supervisors often deferred checking-in with paramedics on medical leave to human resources	•Distrust of calls from the organization
		•Supervisors have not been trained to conduct check-ins during a medical leave and there are no formalized procedures to do so
Meaningful Work Accommodations Paramedics are provided with opportunities to gradually return to the frontline or perform meaningful alternative duties with continuous follow-up.	•Gradual return-to-work options: 3rd in car, reduced hours, reduced shifts, choice of partner/ mentorship program, avoiding peak times	•Difficult to return to the place of trauma
	•Alternative work options: administrative duties, community outreach/ public safety awareness programs, other projects at the organization	•Not much work available and paramedics did not find administrative work to be meaningful

3.1 Primary prevention

When asked about organizational initiatives to help maintain good mental health and prevent PTSI, interviewees acknowledged that exposure to traumatic stressors was unavoidable. Importantly, however, they consistently suggested that having a psychologically safe and healthy work culture, consistent supervisor support, mental health training and awareness, and opportunities for recovery and maintaining resiliency were vital to primary prevention.

3.1.1 Psychologically safe and healthy work culture

Having a psychologically safe and healthy work culture was a recurring facilitator for dialogue surrounding stressors, mental health, and support-seeking behaviours. In fact, it was an overarching theme that both impacted and was impacted by all of the other organizational initiatives. Interviewees agreed that, without a supportive work culture, mental health initiatives would not function as intended, as emphasized by the following statement:

You can have all the policies, programs and practices in place but unless people feel that the organization lives and breathes those policies and practices, they will always be reluctant to report their PTSI challenges. The overall organization in its day-to-day functioning needs to reflect the stated goals of the organization. (Paramedic_03)

In addition, three distinct conceptualizations of PTSI emerged, all required organizational acknowledgment to improve work culture and reduce the stigma associated with PTSI:

PTSI is a legitimate injury: All interviewees shared similar insight that the stigma surrounding mental disorders has significantly decreased; however, there are still remnants of ‘the old, push it down, suck it up and move on attitudes.’ Paramedic_04 expressed how such attitudes within the organization affect self-reporting, ‘People are still afraid to reach out and ask for help because they’re scared of the stigma and scared of not even being taken seriously.’ Key informants indicated that their organizations have shown their recognition for the legitimacy of PTSI through programs and policies such as mandatory mental health training for paramedics. Paramedics and union representatives have also been advocating for PTSI to be recognized and treated to the same degree as physical injuries. Supervisor interviewees mentioned that they, personally, try to ensure that all reports of PTSI are taken seriously and that supports are offered while discouraging and limiting stigmatizing remarks.

PTSI is a normal outcome from exposure to trauma: Interviewees acknowledged that exposure to trauma may result in PTSI; para-doxically, there was also a unanimous understanding that paramedic work requires elevated mental resiliency. These conflicting ideas create a sense of being unfit for the job for those facing difficulties coping and rebounding. Organizations have identified that this issue exists, but face challenges in defining the thresholds to determining whether an individual is psychologically fit for the job. A paramedic supervisor stated that:

... you [paramedics] know the profession you’re getting into, you know what you’re most likely going to come across. We’ve had this discussion about levels before, it’s hard to draw a line as to whether or not you’re suited to the profession. (Supervisor_02)

The underlying idea that paramedics need to be resilient to trauma because it is part of their job was a recurring reason for underreporting.

Mental health supports can be used proactively: According to the interviewees, mental health services have traditionally been used reactively for treatment rather than proactively to monitor mental health. This notion of using mental health services reactively creates an underlying stigma and a concern of being ‘judged’ or ‘treated differently’ for engaging with such services. However, there is an emerging view that mental health supports should also be used proactively. Some paramedics interviewees shared their changing views toward using psychological services as a preventative measure:

The way I look at it now, and I tell my colleagues, it’s actually good to check-in with the psychologist. So having built that rapport when you don’t have any issue so that when you do have an issue, you have someone that you already feel comfortable speaking with ... It’s like having a family doctor, like just to check-in with once in a while. (Paramedic_01)

Normalizing the use of mental health supports as a preventative measure may help reduce the stigma of seeking support.

3.1.2 Consistent supervisor support

Paramedics expressed their desire for consistent supervisor support, often by comparing ‘good’ versus ‘bad,’ ‘old school,’ or ‘disconnected’ supervisors. According to paramedics, supervisor support pertaining to PTSI included demonstrating value for paramedics’ health over key performance indicators (e.g., granting time to diffuse when requested), and providing occasional emotional support, casual check-ins and follow-ups, all in ‘non-invalidating’ and ‘non-judgmental’ ways. However, whether paramedics would be supported ‘depends on the supervisor.’ Supervisors also acknowledged the variability of support amongst their occupational cohort, ‘I think in our supervisor group, there could be some tightening up of our training. There are inconsistencies in how supervisors are responding’ (Supervisor_01). The variability of supervisor support may be explained by a lack of systematic training, a lack of formalized procedures and policies to guide decision-making, and supervisors implementing their personal practices to support paramedics.

3.1.3 Mental health training and awareness

All interviewees shared that their organizations either offer or mandate basic mental health awareness training for paramedics, and that peer supporters receive additional psychological first aid training. They asserted the importance of mental health training and awareness in reducing stigma and creating a shared understanding of PTSI. However, interviewees also noted that the training programs are often too ‘general’ and ‘theory-based,’ making it difficult to put into practice. One paramedic summarized this point by expressing, ‘Well, a course is great, but it’s so generalized because it doesn’t apply to you, yourself’ (Paramedic_02). Although basic training is provided to paramedics, interviewees also noted that they would like their loved ones and mental health professionals to be equipped with the necessary information to effectively provide support (i.e., understanding paramedic culture and their working conditions).

3.1.4 Opportunities for recovery and maintaining resiliency

According to paramedics and union representatives, mental health training needs to be coupled with opportunities to apply it in the workplace, especially for recovery and maintaining resiliency. Paramedics identified many organizational barriers that prevent its application, including shiftwork, the on-call nature of the work, limited rest breaks in high volume areas, and staffing shortages. Interviewees suggested that this creates a dilemma of acknowledging the need for rest and recovery during a shift while not wanting to do a ‘disservice’ that compromises the team’s performance, as summarized in the following quote:

I don’t think the organization allows them [paramedics] to use it right now because if they do use those programs, it’s a negative pressure that’s put on them. So, if you don’t come in and do overtime, you’re making everybody else work harder. If you book off sick or fatigued, you’re making everybody else work harder. (Union Representative_01)

Without opportunities or organizational support to apply the training, training was sometimes perceived as an action item for the organization to complete rather than perceived as a commitment to support paramedics’ mental health and well-being.

3.2 Early detection and intervention

When discussing organizational mechanisms for identifying and supporting paramedics with early signs and symptoms of PTSI, interviewees emphasized the need to account for stressors and symptoms beyond those associated with critical incidents and the need for multiple types of mental health supports to accommodate for individual differences.

3.2.1 Recognition of PTSI and its diverse risk factors

Participants in this study consistently reinforced the need for effective strategies to recognize potential risk factors and signs and symptoms of PTSI to allow supervisors, peer supporters, and others to check-in and offer support. Many interviewees shared that their organizations used a pre-defined list of critical incidents that, in the occurance of one, would initiate a check-in. However, they also acknowledged that the list does not account for unique individual triggers or non-traumatic, chronic, and cumulative stressors that also need organizational recognition and monitoring. In terms of monitoring signs and symptoms of PTSI, formal incident reporting mechanisms are in place for self-reporting; however, those are often underutilized. Many supervisors shared their personal practice of getting to know their staff informally and monitoring behavioural changes. Similar approaches were described:

If I see somebody who’s doing things that they wouldn’t normally do, maybe they’re more short-tempered, they’re lacking patience, or they’re complaining about a lot of things. If I identify those things, I want to start talking about those issues with them to see if there’s anything going on that runs a little deeper than a simple frustration. (Supervisor_01)

Paramedics also suggested that friends and family, if equipped with the appropriate knowledge, could help recognize signs and symptoms of PTSI. Annual checkups with a mental health professional was another common suggestion to monitor and detect potential cases of PTSI proactively and normalize the use of mental health supports.

3.2.2 Variety of support initiatives for PTSI

All interviewees emphasized the importance of having multiple types of mental health supports to accommodate paramedics’ diverse coping strategies for recouping from stress responses, either acute, episodic, or chronic. Paramedic_01 described the variations in how paramedics cope after a critical incident, “For some people, they want to be approached, they want to be asked, ‘Hey, let’s take you off service to talk about it.’ For others, they just want their downtime... Everyone deals with these differently. So, it’s hard to have one thing.” Regardless of the type of support, it needed to be readily available and responsive.

Key forms of supports discussed included downtime, support from colleagues (e.g., partners, peer support, and supervisors), critical incident stress management, and access to professional mental health services (e.g., extended health plans, employee and family assistance program (EFAP) counsellors, (in-house) mental health professionals, formal debriefing). Paramedics have access to most of these supports, but their accessibility, implementation, and effectiveness varied across organizations. Interviewees also described individual-level decision-making processes to seeking support.

3.3 Disability management

With the provision of a medical note, workers’ compensation, and both short- and long-term disability leave may be available to paramedics dealing with work-debilitating PTSI. Sick days and vacation days may also be available for shorter periods. Through the thematic analysis, communication during medical leave and meaningful work accommodations were vital organizational elements for paramedics to engage with the disability management process and return-to-work.

3.3.1 Communication during medical leave

Communication during medical leave was a recurring topic of discussion; however, there is uncertainty on how to execute it effectively. Most paramedic participants suggested that the lack of communication from supervisors during medical leave may create feelings of ‘isolation’ or being ‘forgotten.’ Paramedic_02 explained, ‘So, you give all these years to them, and then you go off, and you’re struggling, and the company doesn’t check-in with you, doesn’t acknowledge the good work that you’ve done, just kind of leaves you hanging.’ Paramedics agreed that check-ins should focus on their health and recovery, and not on the legitimacy of their illness or when they could return-to-work; however, communications during medical leave, according to interviewees, have traditionally been work-related.

From the supervisors’ perspective, choosing not to follow-up with employees was typically due to a concern of ‘re-traumatizing’ the worker, so they would rarely contact workers until it was time to discuss return-to-work. For others, there might be a sense of distrust in paramedics’ illness and recovery process, questioning: are they ‘abusing sick time?’ or ‘is there really a problem still?’ Union Representative_01 summed up the existing gap: there is a need to ‘establish a system where they [paramedics] can trust in those phone calls. Right now, we don’t have a good trusting, healthy system where employers could do that easily.’

3.3.2 Meaningful work accommodations

From paramedics’ and union representatives’ perspective, meaningful work accommodations are central to successful return-to-work and stay-at-work. For paramedics who are ready to be reintegrated back into the frontlines, there are many pre-established options to gradually build capacity towards working full shifts. Such work accommodations included working day shifts only, avoiding peak times, being a third on-car, working reduced hours, or working reduced shifts. For paramedics who are not yet able to or unable to return to the frontlines, finding meaningful work has not always been straightforward. Readily available alternative duties were often administrative tasks, which many paramedics did not find meaningful. The following sentiment was shared amongst all interviewees, ‘ ... sometimes they [paramedics with PTSI] get kind of put into these menial type of clerical tasks ... they do not want that type of task and don’t find that meaningful at all’ (Supervisor_01).

4 Discussion

Based on the disease prevention model for intervention, key informants shared that paramedic services have already considered or implemented initiatives across each level of the model. For primary prevention, key informants reported that most paramedic services provide mandatory mental health training to lay foundational knowledge, ideology, and language surrounding mental health. For detecting early signs and symptoms of PTSI, multiple mechanisms were already in place, including incident reporting, check-ins after a potentially critical incident, informal monitoring of behaviours, and encouragement of self-reporting with reminders of confidentiality. As for early intervention, various types of supports were also offered, including downtime, peer support, critical incident stress management, and access to mental health professionals (either through the extended health plan, a mental health referral network, EFAP, or an in-house mental health professional). Lastly, all participants stated that their organizations had established processes for disability management, including medical leave and negotiating work accommodations. Despite having many of the programs established within each level of the model, there were systemic gaps and challenges to the engagement, implementation, and coordination of the programs, which were often attributed to resource constraints, such as staffing shortages, insufficient training, and lack of formalized procedures and policies. These gaps may lead to feelings of distrust, isolation, and resentment amongst paramedic staff that can rapidly propagate throughout the organization and compromise the work culture [31].

Early and proactive engagement with existing mental health initiatives was a recurring challenge; parallel observations have been reported within the broader paramedic community [13 , 32–34]. Although paramedics were often encouraged to use the services and report early signs and symptoms of PTSI, the organizational culture implicitly discouraged it. For example, organizations may promote the importance of nutrition, sleep, socialization, and exercise for mental and physical resiliency without addressing barriers such as shiftwork, overtime, and minimal breaks that commonly prevent such practices. This is in line with a Canada-wide survey of public safety personnel [11]; among the paramedic sample population, finding time to stay in good physical condition was a leading occupational stressor, subsequent to inconsistent leadership style, bureaucratic red tape, and staffing shortages [11]. Paramedics also felt that requesting downtime risked the stigma of being viewed negatively by others [13, 34]. Ricciardelli et al. suggested that structural stigma within emergency services originates from budgetary constraints, suggesting that individuals who took time off for self-care or to seek support may be the target of resentment by other coworkers simply for offloading work onto others [13]. This resentment often led to other coworkers questioning the legitimacy of the individual’s mental health claim and perpetuated underreporting [13]. Similarly in this study, paramedics may not seek support because it was thought of as ‘a disservice.’ The importance of creating a supportive psychosocial work climate in paramedic services, a modifiable factor which accounts for 13% variance of mental health and well-being [14], cannot be overstated.

Supervisors also play a significant role in paramedics’ mental health and well-being, accounting for 7% and 10% variance of mental health and well-being, respectively [14]. They have the authority to grant requests for downtime, initiate support services, provide support by checking-in and following-up with the paramedics and support services, and negotiating work accommodations. However, for such a critical role in the prevention and management of PTSI, they have received limited training and resources. Firstly, training in mental health or mental health first aid has not been mandatory for supervisors, and many felt ill-prepared to provide emotional support, a finding similar to Brooks [35] and Kellner et al. [36]. Secondly, the limited training, combined with a lack of formalized policies and procedures, resulted in reliance on personal judgment, beliefs, and values on mental health; this was particularly detrimental for self-reported critical incidents or chronic stress. Consistent with previous work [11], this study found varying support levels from the supervisory staff. Supervisors have also mentioned a lack of organizational support for their own mental health, underscoring the need for top management commitment to address PTSI at the organizational-level [37].

Although organizations have interventions for primary prevention, early detection and intervention, and disability management (which may appear to be a comprehensive approach to addressing PTSI), there were systemic challenges with coordination, resource allocation, and worker engagement to improve the effectiveness of the interventions. These systemic challenges suggest that the organizational elements identified from the interviews may be critical but insufficient to address PTSI optimally and that there is an urgent need for paramedic services to foster a culture where the commitment to employees’ mental health is integrated into day-to-day organizational operations.

Applying the paramedic-specific considerations for the organizational elements identified in this study into a broader organizational management systems framework may help to ensure that resources are available, coordinated, and effectively implemented. Management systems include additional elements that may be critical in addressing PTSI in the workplace, such as top management and leadership commitment to improving psychological health and safety (including the provision of adequate resources), worker participation, confidentiality, and performance measurement and monitoring [23 , 39]. Management systems for health and safety has been suggested to be an efficient way to use organizational resources and positively impact employees’ health, safety, and attitudes [10 , 40].

Limitations of the study should be noted. This study had a small sample size with representation from many, but not all, jurisdictions in Canada. Despite the small sample size, saturation was reached based on the recurrent themes that emerged and limited new information in the latter interviews. The balanced participation between paramedics and supervisors also assures that the results were not biased towards a single occupational group’s perspective. Whether interviewees had stronger (both positive or negative) opinions and experiences towards their organization’s mental health initiatives cannot be confirmed, but there is an assurance by the consistency of responses across the elements.

5 Conclusions

This study reported key informants’ perspectives and insights on the desired organizational elements, as well as the existing initiatives, barriers, and potential solutions to address PTSI among Canadian paramedics utilizing the disease prevention model for intervention. The findings suggest that, in addition to implementing initiatives at each level of intervention, organizations must also overcome broader underlying organizational barriers to optimally addresses PTSI. These barriers include resource constraints and a lack of formalized PTSI-related policies and procedures. In other words, addressing PTSI requires more than implementing stand-alone initiatives such as mental health training, peer support, EFAP, extended health plan, and work accommodations. The organization must also provide adequate resources and formalized policies and procedures to further facilitate worker engagement, coordination, and implementation. These findings are critical for top-management and policy-makers overseeing organizational initiatives to address PTSI. Integrating the eight organizational elements identified in this study into broader existing management system frameworks may have merit in overcoming the systemic barriers when addressing PTSI.

Funding

This work was supported by the Defence Research and Development Canada under Grant CSSP-2017-CP-2310. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the funders.

Conflict of interest

The authors declare no conflicts of interest.

Footnotes

Acknowledgments

The authors would like to acknowledge their research participants and industry partners who generously shared their time, experience, and insight for this project. The authors would also like to thank Dr. Amy Hackney for proofreading the article.

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