Ambulance personnel’s perceptions on their workplace well-being: A descriptive interpretative study

Abstract

BACKGROUND:

Ambulance personnel face numerous challenges during their working hours. Exposure to stressful situations and other factors in the outpatient emergency medical service can affect the health of ambulance personnel as well as their well-being.

OBJECTIVE:

The main objective of this study was to explore the perceptions of ambulance personnel regarding their physical and mental well-being at the workplace.

METHODS:

A qualitative descriptive-interpretative research design was used. Individual face-to-face and online interviews were conducted between February and April 2022. A total of 26 interviews were conducted to explore employees’ perceptions regarding the impact of work on their health and well-being.

RESULTS:

Ambulance personnel described in detail their perceptions of the impact of work on their physical and mental health and well-being. Three main themes emerged from our data: 1) the impact of work on the psychophysical condition of ambulance personnel; 2) the impact of work on the lifestyle of ambulance personnel; 3) the impact of work and the work environment on the lives of ambulance personnel.

CONCLUSION:

Long-term work in emergency medical services affects the health and well-being of ambulance personnel. As demonstrated by this study, raising awareness on the importance of preventive and health promotion programmes, understanding employees’ problems by considering their opinions, and providing relevant training are extremely important tools for preventing such problems among employees.

Keywords

Emergency medical services health promotion occupational health

1 Introduction

The work of ambulance personnel in an outpatient emergency medical service unit presents numerous challenges. What is specific of this work is that employees must often take prompt measures and provide medical care under pressing circumstances while being surrounded by onlookers. In addition to working under such extreme conditions, ambulance personnel must also perform non-emergency tasks, such as the transport and care for the chronically or terminally ill [1]. It is also important to note that employees work in shifts, with a rotating shift being a combination of a night shift and a day shift in one shift schedule, with days off scattered in between shift schedules. As ambulance personnel are more susceptible to health-related problems such as physical and mental issues [2], shift work is believed to have become a serious public health concern [3].

Furthermore, ambulance personnel are repeatedly exposed to potentially traumatic events (death, injury, violence) at a significantly higher rate than most other professional groups [4]. Exposure to traumatic events poses an increased risk to one’s mental health [5]. While post-traumatic stress disorder (PTSD) is most commonly mentioned in the literature, it is also important to highlight other problems that can occur, such as depression, anxiety, and general psychological distress [6].

Aside from psychological effects, significant physical problems have also been reported in the form of musculoskeletal injuries associated with patient weight and manual handling requirements [7]. Exposure to occupational stress has also been reported, which may result in headaches, sleep disturbances, fatigue, eating problems, weight gain, and in some cases, exposure to dangerous pathogens [8]. More than 88% of ambulance personnel reported at least one cardiovascular risk factor [9], which represents one of the main public health concerns.

Daily habits and behaviours, which include proper nutrition and physical activity, are important for a healthy lifestyle, as they reduce the risk of chronic diseases and improve one’s health and quality of life [10]. Although individuals make decisions about food choices and physical activity levels, these habits are partly determined by social, behavioural and personal factors [11]. Ambulance personnel exhibit low adherence to physical activity guidelines and a high prevalence of obesity and injuries. Barriers to adherence to physical activity guidelines include lack of energy, lack of willpower, lack of time, social influences, and lack of resources [12]. While insufficient physical activity is one of the main reasons for excessive weight gain, some authors argue that due to the specific nature of their work, the possibility of receiving an emergency call at any time, and considerable amount of time spent in vehicles, ambulance personnel eat “opportunistically", which may negatively affect the quality of their diet and result in body weight changes [13].

Due to the specific nature of their work, ambulance personnel also face unpredictable situations and extended work hours that can affect their sleep [14]. Inadequate or disrupted sleep has been associated with cardiovascular disease, metabolic disease, depression, impaired immune function, and hormone secretion fluctuations, which may trigger negative psychological changes [15].

In addition to the nature of their work, ambulance personnel are also influenced by other factors such as high workloads, work demands, shift work, limited time for debriefing or downtime, hierarchical supervision, and lack of recognition, which are as significant as the nature of the work itself, if not more so [16]. Therefore, the main objective of this study was to explore the perceptions of ambulance personnel on their physical and mental well-being at the workplace that would serve as a platform for the development of health promotion programme for ambulance personnel.

2 Methods

2.1 Study design

Qualitative methodology was used for the study, in which the researcher collects, processes, describes, analyses and interprets the results obtained [17]. The qualitative research method is used when the researcher is interested in understanding people’s actions and behaviours. Qualitative research is usually conducted on a smaller number of subjects and rely on larger amounts of data and more detailed opinions [18]. The qualitative method allows for the examination of descriptive details, which underscores the importance of contextual understanding of social behaviour, as understanding a specific context can explain seemingly odd or irrational behaviour [19]. As part of the qualitative methodology, a descriptive-interpretive method was chosen to gather specific and targeted data about the observed phenomenon [20].

The study is based on Whitehead and Dahlgren’s [21] Rainbow model, the centre of which is represented by individuals’ age, sex and constitutional characteristics that influence their health and are largely fixed. Surrounding them, however, there are influences that can in theory be modified by internal and external factors, such as individuals themselves through their behavior, the environment, or for example, policies. First, there are factors of personal behaviour, such as smoking habits and physical activity. Second, individuals interact with and are influenced by their peers and environment. Next, a person’s ability to maintain health is influenced by their living and working conditions, food supply, and access to essential life resources. Finally, economic, cultural and environmental influences in society play important roles as mediators of population health.

2.2 Study setting

The research was conducted in Croatia, at the Teaching Institute for Emergency Medicine of the County of Istria, which employs a total of 206 staff members (physicians, nurses and drivers) working in outpatient emergency medical service teams. In their daily operations, the outpatient emergency medical service units in the Republic of Croatia use different types of teams, depending on the specific area and existing network of teams. The so-called T1 teams consist of three members: a physician, a nurse and a driver. Due to a number of challenges, such as increasing staff turnover, medical staff shortages, e.g., physicians participating in medical specialisation programmes or moving abroad [22], T2 teams have been set up, which consist of two nurses or one nurse and a driver who also works in the emergency medical services system.

2.3 Sample

Within qualitative methodology, opinions are divided on what sample size is sufficient (i.e., how many participants are needed) to conduct research. For example, Moser and Korstjens [23] argue that 15 participants is the minimum number needed to conduct qualitative research using the descriptive-interpretive method. On the other hand, there are authors who believe that this number should be much higher [24]. It is believed that the key to determine sufficient sample size is to identify why a particular sampling method was chosen and why the sample size achieved is acceptable. It is important to recognize that theoretical saturation has been reached. In this case, specifying the maximum or minimum number of samples is meaningless. Thus, the criterion for determining the sample size is whether or not saturation has been achieved [19].

A total of 26 interviews were conducted: 9 with physicians, 11 with nurses, and 6 with drivers –all members of emergency service teams. The youngest participant was 25 years old; the oldest participant was 62 years old. The minimum length of work experience was 1 year, and the maximum length of work experience was 41 years (Table 1).

Table 1
Demographic data of interviewees

Position Identifier Gender Age Work Type of employment

experience contract

Nurse Nrs_1 Female 40 20 Permanent

Nurse Nrs_2 Female 58 40 Permanent

Nurse Nrs_3 Female 30 10 Permanent

Nurse Nrs_4 Female 61 41 Permanent

Nurse Nrs_5 Female 59 40 Permanent

Nurse Nrs_6 Female 60 30 Permanent

Nurse Nrs_7 Male 26 7 Permanent

Nurse Nrs_8 Female 26 6 Permanent

Nurse Nrs_9 Female 38 17 Permanent

Nurse Nrs_10 Female 45 10 Permanent

Nurse Nrs_11 Male 40 2o Permanent

Physician Phy_1 Male 26 1 Fixed-term

Physician Phy_2 Female 26 1 Fixed-term

Physician Phy_3 Female 29 2 Fixed-term

Physician Phy_4 Female 62 32 Permanent

Physician Phy_5 Male 27 2 Permanent

Physician Phy_6 Female 27 2 Permanent

Physician Phy_7 Female 30 3 Permanent

Physician Phy_8 Female 54 25 Permanent

Physician Phy_9 Female 35 10 Permanent

Driver Dr_1 Male 40 3 Fixed-term

Driver Dr_2 Male 32 2 Fixed-term

Driver Dr_3 Male 37 6 Permanent

Driver Dr_4 Male 40 10 Permanent

Driver Dr_5 Male 40 8 Permanent

Driver Dr_6 Male 39 6 Permanent

Position	Identifier	Gender	Age	Work	Type of employment
Nurse	Nrs_1	Female	40	20	Permanent
Nurse	Nrs_2	Female	58	40	Permanent
Nurse	Nrs_3	Female	30	10	Permanent
Nurse	Nrs_4	Female	61	41	Permanent
Nurse	Nrs_5	Female	59	40	Permanent
Nurse	Nrs_6	Female	60	30	Permanent
Nurse	Nrs_7	Male	26	7	Permanent
Nurse	Nrs_8	Female	26	6	Permanent
Nurse	Nrs_9	Female	38	17	Permanent
Nurse	Nrs_10	Female	45	10	Permanent
Nurse	Nrs_11	Male	40	2o	Permanent
Physician	Phy_1	Male	26	1	Fixed-term
Physician	Phy_2	Female	26	1	Fixed-term
Physician	Phy_3	Female	29	2	Fixed-term
Physician	Phy_4	Female	62	32	Permanent
Physician	Phy_5	Male	27	2	Permanent
Physician	Phy_6	Female	27	2	Permanent
Physician	Phy_7	Female	30	3	Permanent
Physician	Phy_8	Female	54	25	Permanent
Physician	Phy_9	Female	35	10	Permanent
Driver	Dr_1	Male	40	3	Fixed-term
Driver	Dr_2	Male	32	2	Fixed-term
Driver	Dr_3	Male	37	6	Permanent
Driver	Dr_4	Male	40	10	Permanent
Driver	Dr_5	Male	40	8	Permanent
Driver	Dr_6	Male	39	6	Permanent

The selection of participants was purposive; an invitation to participate in the study containing all the relevant information about the study was sent via e-mail and notification to emergency departments. There were a total of 26 interested participants. The saturation criterion was met after 22 interviews, but after reflective discussion, an overview of preliminary data analysis and participant willingness, the authors decided to conduct all interviews.

2.4 Data collection

Individual face-to-face interviews were conducted in person and online in the Croatian language in the period between February and April 2022. Due to self-isolation measures related to the COVID-19 pandemic, some interviews were conducted online via the Zoom platform (11 interviews), while the remaining part of the interviews was conducted in person (15 interviews). Since all live interviews took place in a peaceful and privacy-preserving environment, the participants in online interviews were also asked to be alone in the room to achieve the same effect. At the beginning of each interview, the interviewer explained the goal of the study, after which participants signed the informed consents. Each interview was audio-recorded. These recordings are kept in a file by the author and are protected by a password.

2.5 Data analysis

Each interview was transcribed verbatim immediately after its completion. Analysis was performed with the ATLAS.ti software package (Scientific Software Development GmbH, Federal Republic of Germany). A thematic analysis approach was used, which, according to Steen and Roberts [25], involves rereading the entire transcript up to the point when coding can begin, separating data into smaller units, and categorising these units, i.e. data coding. Finally, themes were developed from the established categories, representing a description or interpretation of the studied phenomenon.

Inductive coding, also known as open coding, was used in the analysis of the data. This is a process of categorising and classifying data by assigning codes to individual parts of the text. To organise the data, the text assigned the same code was separated from the rest of the text and merged together [26]. Thematic analysis of the transcribed interviews was performed by all authors in unsupervised steps.

2.6 Ethical aspect

The research and the research method were approved by the Ethics Commission of the Teaching Institute for Emergency Medicine of the Istria County (February 1, 2022).

Participation in the survey was voluntary for each respondent and could be withdrawn at any time without sanctions. The names of all participants were anonymised and replaced with a unique code. Each participant was assigned a unique label. Participating physicians were labelled “phy” followed by the interview number, nurses were labelled “nrs” followed by the interview number, while drivers were labelled “drv” followed by the interview number.

2.7 Rigour and trustworthiness

Several measures were taken to ensure the trustworthiness of the study, whereby the focus was on the criteria of credibility, transferability, reliability and confirmability according to Bryman [19]. All transcripts were read multiple times in order to gain a better understanding of the impact of work on the health of ambulance personnel. Significant themes were identified through open coding of the interviews, and data were coded line by line. Two authors interpreted the data and discussed the potential new themes. The final decision on the identified themes and subthemes was based on the discussion and agreement of all authors, all of whom had experience in qualitative data research. In order to meet the criteria of reliability and transferability, each stage of the research process is documented in detail.

3 Results

The analysis resulted in the following themes: (1) the impact of work on the psychophysical condition of ambulance personnel; (2) the impact of work on the lifestyle of ambulance personnel; (3) the impact of work and the work environment on the lives of ambulance personnel (Table 2).

Table 2
Defined themes

Theme Subtheme Examples

The impact of work on the psychophysical condition of the ambulance personnel Impact on the physical and psychological well-being of employees “...I have noticed that I mirror some of these emotions, I feel anxious, my voice is breaking and when talking to them I feel that my voice sounds uncertain.” (phy_5)

Reasons for experiencing physical and psychological problems “We start without any warm-up and no one is prepared when we are called on interventions, our bodies are tense most of the time and you always carry the patient in some unnatural body position.” (drv_6)

The perception of individual preventive behaviour and existing preventive measures in the work environment “We can help ourselves by thinking about the correct posture when lifting, squat more correctly, but I‘m always looking out for the patient’s benefit, not my own.” (nrs_3)

The impact of work on the lifestyle of ambulance pesonnel Causes of changes in eating habits and their impact on employees “Night shifts are the problem, you come back from an intervention in the middle of the night and you’re hungry, you are forced to eat some nonsense just to satisfy your hunger.” (drv_4)

The influence of work on physical activity “I plan to work out that day and then I come home from the night shift feeling tired and do none of the things I was planning to do.” (nrs_8)

Tobacco and alcohol consumption “I really drink occasionally; I really don’t see alcohol as a problem. I wouldn’t associate it with work.” (nrs_1)

Employees’ perspectives on lifestyle improvements “Maybe it’s a good thing that some companies have certain contracts with fitness centres where part of the membership fee for the gym or other physical activities is subsidised.” (phy_5)

The impact of work and the work environment on the lives of ambulance personnel Difficulties in social relationships “My wife works during the week, there is no school on the weekends, we would like to go somewhere together, and when I work, it affects my personal quality of life, which bothers me the most.“ (nrs_11)

The impact of work on employees’ sex life “...when you finish a medical intervention with a good result, you feel powerful and feeling powerful is a libido booster, so it might have a good effect after all.” (phy_3)

A sense of safety, appreciation, and a positive work atmosphere “Is soemone going to come in with a weapon and attack you? Is soemone going to physically come at you? Because, verballly, we get attacked every single day.“ (nrs_5)

Theme	Subtheme	Examples
The impact of work on the psychophysical condition of the ambulance personnel	Impact on the physical and psychological well-being of employees	“...I have noticed that I mirror some of these emotions, I feel anxious, my voice is breaking and when talking to them I feel that my voice sounds uncertain.” (phy_5)
	Reasons for experiencing physical and psychological problems	“We start without any warm-up and no one is prepared when we are called on interventions, our bodies are tense most of the time and you always carry the patient in some unnatural body position.” (drv_6)
	The perception of individual preventive behaviour and existing preventive measures in the work environment	“We can help ourselves by thinking about the correct posture when lifting, squat more correctly, but I‘m always looking out for the patient’s benefit, not my own.” (nrs_3)
The impact of work on the lifestyle of ambulance pesonnel	Causes of changes in eating habits and their impact on employees	“Night shifts are the problem, you come back from an intervention in the middle of the night and you’re hungry, you are forced to eat some nonsense just to satisfy your hunger.” (drv_4)
	The influence of work on physical activity	“I plan to work out that day and then I come home from the night shift feeling tired and do none of the things I was planning to do.” (nrs_8)
	Tobacco and alcohol consumption	“I really drink occasionally; I really don’t see alcohol as a problem. I wouldn’t associate it with work.” (nrs_1)
	Employees’ perspectives on lifestyle improvements	“Maybe it’s a good thing that some companies have certain contracts with fitness centres where part of the membership fee for the gym or other physical activities is subsidised.” (phy_5)
The impact of work and the work environment on the lives of ambulance personnel	Difficulties in social relationships	“My wife works during the week, there is no school on the weekends, we would like to go somewhere together, and when I work, it affects my personal quality of life, which bothers me the most.“ (nrs_11)
	The impact of work on employees’ sex life	“...when you finish a medical intervention with a good result, you feel powerful and feeling powerful is a libido booster, so it might have a good effect after all.” (phy_3)
	A sense of safety, appreciation, and a positive work atmosphere	“Is soemone going to come in with a weapon and attack you? Is soemone going to physically come at you? Because, verballly, we get attacked every single day.“ (nrs_5)

3.1 Theme 1: The impact of work on the psychophysical condition of ambulance personnel

Respondents reported musculoskeletal problems as the most common type of physical problems, citing back pain and spinal problems as occurring the most frequently. They also reported experiencing bone, joint and muscle pain.

Other problems they mention are issues associated with the cardiovascular system, which they believe are the main reason for taking sick leave or changing jobs. Respondents believe that working in the emergency medical services leads to chronic fatigue.

“Muscle strains, pinches in the spinal area, especially in older employees, reactivated old injuries, knee injuries and the like.” (phy_7)

“. . .in older employees, especially men, elevated blood pressure, cardiac arrhythmias, stent placement, acute myocardial infarctions, causing them to take sick leave and change jobs.” (phy_8)

On the other hand, respondents state that the most common psychological problem is stress, which occurs for various reasons, and that they feel mental exhaustion due to the work they do. In the long term, they feel mood swings, lack of empathy and experiencing patients’ emotions.

“. . .we are mentally exhausted because we work in clinics during the summer for the whole shift and then we need to be rested and focused for the actual interventions . . . ” (nrs_7)

“. . .when something happens to you at home, you don’t react. . .we are a bit limited in empathy. . .” (nrs_8)

It is important to understand employees’ views on the reasons for the occurrence of physical and psychological problems. Respondents believe that lifting and carrying heavy equipment, moving patients, and working in the field, which often requires unnatural postures, are the main reasons for the occurrence of physical problems.

“The work is organised in such a way that there are three team members, the equipment itself is heavy, a recent weighing showed that we carry over 50 kg of equipment plus the weight of the patient.” (phy_8)

“. . .the inaccessibility of the terrain, which means that sometimes we go into the sea, into holes, into bushes, when it rains, when it’s dark. . .” (nrs_2)

Treating pediatric patients, confronting death and caring for dying patients, waiting for emergency calls and feeling uncertainty are the causes for developing psychological problems.

“You always make children a priority, we see them differently, we treat them differently.” (drv_5)

“. . .being confronted with death, maybe not so much with death but with the moments leading to death, either of patients or the effect it has on their families, that really hurts. . .” (phy_5)

“. . .you cannot predict what to expect, what kind of patient is going to arrive, what kind of call you are going to receive, that alone raises your levels of adrenaline and cortisol as stress hormones, which certainly affects the whole body.” (phy_8)

Communication is always a challenge, and respondents state that communication with other healthcare facilities is often a cause of stress, and on the other hand, it also happens that communication within the team can cause problems. In addition to communication, they also consider the healthcare system in which they work to be problematic.

“. . .in our work setting, there are three team members with different levels of education and upbringing. Added to that is the fact that this is a more high intensity work in the sense that emotions can take over.” (phy_8)

“Sometimes I wonder why I do this, especially when treating non-emergency patients, because it’s more a question of collaboration between primary care physicians and community health centres.” (phy_5)

Among sleep difficulties respondents mention waking up very early, restless sleep, problems falling asleep, and poor sleep quality. In their opinion, these problems are caused by changes in the environment and their sleep routine, which lead to disturbances in their biorythm.

“Sometimes there comes a phase when I can’t sleep at all, I wake up every hour, and that affects the body and everything else. The older you get, the longer it takes to recover after a sleepless night.” (drv_5)

“. . .your biorhythm changes completely, especially during night shifts.” (phy_6)

Sleep difficulties can have a negative impact on employees’ personal lives and cause negative mood. Of particular concern is that respondents indicate that their consumption of sleeping medications has increased, which not only affects them, but also the quality of patient care during night shifts.

“I see this in the younger generations. 25- or 26-year-olds come into contact with sedatives, with hypnotics, and they have great difficulty sleeping. To me, that is really unusual. This used to be reserved for older people, but now I see younger people taking these meds.” (phy_8)

“Our work productivity definitely goes down when we work night shifts. The quality of work suffers.” (phy_5)

One of the respondents’ suggestions on how to help reduce physical problems was to purchase more appropriate and automated equipment for employees to use in patient care. Respondents also note that there should be better collaboration with other emergency services such as the fire department. In addition, they believe they could personally contribute to this by educating themselves on the proper way to lift and carry loads and increasing their personal physical fitness to better perform their work tasks. Regular medical examinations should be more frequent and thorough so that quick action can be taken when difficulties occur.

“I feel that the equipment is procured without consulting the workers who use it. Our dream is to have a hydraulic stretcher so that we don’t have to hurt our spine when lifting the patient.” (nrs_7)

“The assistance of other emergency services, for instance firefighters or the police, who can help us lift a patient.” (nrs_2)

“. . .by having regular examinations at the occupational medicine clinic for early detection of any conditions. Prevention is key.” (phy_1)

Psychological problems could be alleviated by improving communication with other services and communication within the team. Respondents also believe that organised psychological help would be useful in making psychological problems easier to manage.

“You should discuss these things with your team members more often, good communication is very important.” (phy_5)

“In terms of mental health, we experience many intense situations. So if someone is emotionally illiterate, it will affect them much more, even if it is just an obligation to contact a professional.” (phy_3)

Respondents state that existing preventive programmes are not sufficient and they believe that there is a need to introduce new preventive and health promotion programmes, but they see obstacles in the form of finances, disinterested management, and unmotivated employees.

“We would probably benefit from happier and healthier workers who would take sick leaves less often, and do their jobs better, but the potential for that is not recognised.” (phy_2)

“That would be very good, they would be even more professional, their stress levels, physical and mental problems would be reduced.” (drv_5)

“The funding and everything else should come from our superiors. I think they would be the ones to prevent it, but they should be the ones to encourage it.” (nrs_1)

3.2 Theme 2: The impact of work on the lifestyle of ambulance personnel

Respondents believe that the capacity and nature of their work is one of the causes for the changes in their eating habits; in particular, they mention working night shifts and lack of availability of healthy food.

“We don’t know whether we will eat during the day or not, whether that meal will be pastries or a cooked meal, we can bring food but we may not be able to eat it. Physicians and nurses especially have so much work to do that they eat standing up and eat whatever is available.” (drv_5)

These factors have an impact on employees, at times making them feel irritable and unmotivated to eat healthily. They also report that they have noticed changes in their body weight.

“What can happen if you don’t eat is that you get really hungry. People get irritable because of that.” (drv_2)

“During shift work, people probably lose the will to think about eating a better diet, they think more about what is available to them at the moment.” (phy_6)

Some respondents believe that the job increases employees’ motivation to engage in physical activity. Although motivated, the respondents state that they often find exercising challenging due to shift work.

“For me, my work affects my motivation. The moment I decided to continue working in the emergency room, I realised that I had to maintain my physical fitness if I wanted to endure such a burden.” (phy_4)

Some respondents believe that working in the emergency medical services leads to an increase in tobacco and alcohol consumption. On the other hand, some respondents believe that the use of tobacco and alcohol is individual and not related to work.

“I know some colleagues who did not smoke before they came to this workplace. Within a year or two, they all started smoking. They were anti-smokers before, so I think it is related to work.” (nrs_3)

Respondents’ suggestions on how to increase the level of physical activity amongst emergency workers include providing exercise rooms and organising joint sports events. In order to motivate emergency workers for physical activity, respondents also believe that co-funding of physical activity would be helpful.

“Arrange for the infrastructure to be available to employees so that they can exercise even after their shift. The gym should be located at or near the workplace so that they do not have to go far.” (phy_9)

In order for employees to eat a better and healthier diet, respondents believe that the employer needs to arrange for employee meal benefits. In this context, they also believe that pepared meals should be made available to other emergency services, and that the employer should arrange for the availability of healthy food at the workplace.

“It would be nice if we had one meal, a normal meal consisting of soup and the main course. At least one meal at noon.” (nrs_6)

“It would be great if the company provided a certain amount of fruit, freshly squeezed juices, so that you could grab some fruit quickly instead of fast food.” (nrs_10)

3.3 Theme 3: The impact of work and the work environment on the lives of ambulance personnel

Respondents state that the quality of their relationships with family and friends has deteriorated because of their work, and that they have difficulty organising their free time. In their private lives, respondents report noticing changes in their own behaviour.

“When I come home from the night shift, I’m nervous; it takes time for me to start functioning normally. I start shouting out of nowhere, and it’s no one’s fault. Any little thing throws me off track. If I see no other reason, I associate it with work.” (nrs_5)

Employees feel the need to identify with work, they have difficulty separating their private and professional life, and that affects their personal life, but what they feel is very important is the social support they have.

“. . .My family at home and the people around me say, ambulance worker, that’s the real you. They are right. It’s who I am, when there’s no one to answer the emergancy call, and I know it’s an emergancy, I get dressed and head straight to the department. I leave my home and get it done. So yes, my work has taken 100% of me.” (phy_4)

“The fact is we are in the healthcare profession, you have to accept and love the health worker as they are.” (nrs_10)

Some of the respondents believe that working in the emergency service has a negative impact on their sex life, while others consider the impact positive.

“. . .if you are tired or nervous, of course it affects you. You are not in the mood for anything, let alone sex. You are not relaxed, you are subconsciously thinking about work, and that affects your family.” (nrs_1)

Respondents report that there are certain reasons for feeling secure in the workplace. Most of them state that it is precisely the team members who give them a sense of security. Some of the reasons for the sense of security are also the equipment they work with and the training they receive, which makes them feel more confident about how to handle different situations.

“My colleagues give me a sense of security. If an aggressive patient arrives, my colleagues will immediately jump to my defence” (phy_7)

“Before we got new vehicles, we drove an old van with 400 000 km mileage. Now we feel safer and the vehicle itself gives us that same feeling ” (drv_6)

On the other hand, in addition to the factors that make them feel safe, employees feel insecure for some reasons such as field work, driving in a van, inaccessible terrains and unpredictable situations.

“We have to be around patients during transport, we cannot tie ourselves down and do nothing, so I’m not sure.” (nrs_4)

Regarding positive work atmosphere, the respondents state that mutual communication is key, that they feel good when they can communicate regularly with team members at work. In terms of organisation, communication with their supervisors and the feeling of their work being valued is also important to them.

“. . .if one’s hard work was appreciated, this would automatically be a more relaxed, safer and happier work environment. The work environment is what matters.” (drv_3)

“If the communication amongst colleagues was better, if we had get-togethers at times, if we were friends, the work environment would be more pleasant and supportive. Because you spend 12 hours every day with them.” (phy_1)

In terms of the monthly income, the majority of respondents working as physicians believe that their monthly income is sufficient, while a large proportion of nurses and drivers believe that their monthly income is not sufficient for them to lead a healthy lifestyle, and some respondents state that they are forced to look for additional sources of income.

“The monthly income is far above Croatia’s average and definitely enough for a normal and pleasant life.” (phy_5)

“I have to find additional sources of income. During the summer, I have to find additional work to cover all my expenses.” (drv_1)

4 Discussion

Working in the outpatient emergency medical services has a significant impact on the health and personal well-being of employees. Sterud et al. [1] find that outpatient emergency service employees experience greater health problems compared to the general population.

A study conducted in Japan by Okada et al. [27] shows that a large proportion of emergency service employees, up to 40%, suffer from low back pain. This study provides evidence for the occurrence of other health problems, such as knee, neck and shoulder pain [28]. As indicated by the results of this study, one of the causes of musculoskeletal problems is inaccurate and unnatural body posture due to working on site, in vans and on inaccessible terrain.

According to our findings, ambulance employees believe that the introduction of automated equipment for lifting patients would help prevent such problems, which is also supported by other research on this topic. Lad et al. [29] show that electric stretchers can provide both biomechanical and physical support to rescue workers when performing tasks such as lifting and lowering. The introduction of automated equipment in outpatient emergency services should be a priority, as the benefits of using such equipment have been shown to outweigh the costs in the long term. The study by Butt [30] demonstrated that the introduction of hydraulic stretchers reduced the number of sick days from 686 to 344, resulting in significant financial savings. According to a cost-benefit analysis reported by Armstrong et al. [31], the costs of hydraulic stretchers can be fully reimbursed over a period of 7 years.

Rębak et al. [32] show that working in the emergency services can also affect other body systems; employees’ heart rates were raised before they started their work shifts. Metabolic syndrome, a risk factor for cardiovascular disease and type II diabetes, has been shown to be more prevalent among ambulance personnel compared to the general population. The subjects in our study report a similar problem, but they also report experiencing tachycardia when cell phones or doorbells ring in the clinic, and they state that they experience tachycardia when they suddenly get out of bed, which makes it even more difficult for them to work and concentrate on working with the patient.

In addition to the physical difficulties, employees face numerous psychological difficulties. Petrie et al. [33] point out that ambulance personnel worldwide have a significantly higher incidence of PTSD than the general population. Furthermore, Mishra et al. [34] report that 5% of ambulance personnel had fully developed PTSD and that as many as 83% met at least one criterion for PTSD but had not yet developed the syndrome. In addition to PTSD symptoms, research shows that employees also exhibit other signs; a 10% prevalence of depression and 22% prevalence of anxiety has been observed in ambulance personnel [35]. In this study, respondents state that they often think about work, images from interventions appear in their minds, and that certain places remind them of negative situations experienced during interventions, which has also been documented in previous research.

Respondents believe that they handle too much work in terms of treatment and examination of patients whose condition is not life-threatening and who should not fall within the remit of emergency medical services. This frustrates and depletes them, and consumes the energy they need to deal with emergency patients. They believe that they cannot recover sufficiently between difficult interventions in order to be ready for the next task. This is consistent with the study by Alexander and Klein [36], who find that the time for recovery between critical events is insufficient in some cases, as 69% of ambulance employees in their study felt that they did not have sufficient time to recover.

This study shows that employees are aware of their need for psychological help. They believe that their employer is not sufficiently informed about where they can get help. They often seek help by talking to other colleagues who are going through the same or similar situation and try to help each other, but they are aware that they are not capable of solving such situations on their own and that they need professional help. It is important that ambulance organisations routinely offer help and support from psychologically trained personnel in order to deal with difficult professional events in the best way possible [37]. Organised psychological help, along with education on the importance of seeking psychological help and relaxation techniques, is one of the most important suggestions made by respondents on how to prevent psychological consequences.

Research conducted in the U.S. shows that there is a higher prevalence of poor sleep among ambulance personnel compared to the general population [38]. Respondents believe that sleep is one of the factors that has the greatest impact on their health and sense of satisfaction in both their professional and personal lives. They state that they have noticed disturbances to their biorhythm, and that they feel more negative effects as the years go by. They notice waking up earlier than usual, experience interrupted sleep patterns, as well as problems falling asleep. Even when they manage to fall asleep, they feel that their quality of sleep is poor, which is consistent with previous research that shows that short and long sleep durations and poor sleep quality, especially among shift workers, contribute to disruptions in normal circadian rhythms [39]. This desynchronisation of circadian rhythms triggers physiological changes such as increases in cortisol levels, heart rate, blood pressure, and inflammation, thus increasing the risk of developing chronic diseases, such as cardiovascular disease, diabetes mellitus, and hypertension [40]. Of particular concern is respondents’ use of pharmacological agents in order to be able to sleep during their free time. On the other hand, in addition to the impact on employees, respondents believe that patient care during night shifts is of lower quality. This doubt has also been raised by research stating that poor sleep and stress are associated with the development of chronic health conditions, such as cardiovascular disease, as well as potential patient safety concerns [14].

Past studies have highlighted the link between working rotating shifts in a range of work environments and the development of negative health outcomes, such as increased body weight, hypertension, dyslipidaemia, impaired glucose and insulin function, as well as other health implications such as sleep disturbances and digestive problems [11]. In this study, respondents report experiencing eating habit disorders and body weight changes, which they associate with working in the emergency medical services. They find eating properly challenging and state that they often eat fast food standing up due to their work style and lack of time. According to studies on shift workers from other professions, cravings, hunger and fatigue are interrelated issues, which lead workers to reach for sugary snacks or drinks [41].

Our research shows that employees believe that working in the emergency services requires top physical fitness and some express the belief that they are highly motivated to engage in physical activity. Otherwise they feel inadequately prepared to perform work duties, which supports the Sheridan’s [42] thesis that completing a twice-weekly exercise intervention to counteract the sedentary nature of the role and improve performance of difficult tasks improves physical fitness, thus enhancing ambulance personnel’s work capacity and performance. On the other hand, despite employees’ motivation, shift work, along with the mentioned physical and psychological problems, chronic fatigue is a significant hindrance to emergency workers’ engagement in physical activity, which leads to additional problems. The physical fitness of ambulance personnel is believed to be poor due to the prevalence of obesity [43].

A large body of research shows that the health of employees is influenced by their work. However, a smaller number of studies suggest that working in the emergency medical services has an impact on the social life of employees. One of the studies shows that difficulty maintaining social relationships, especially for employees who are in a relationship or marriage, is one of the reasons why employees decide to change jobs [44]. This research shows that employees experience major problems maintaining social relationships such as friendships and family relationships. They believe that due to their specific work, fatigue and stressful situations, they are often intolerant in social relationships, lack empathy, react negatively more quickly, and that their friends and family often feel annoyed, which consequently affects them as well. On the other hand, their social life also suffers on account of the fact that many identify with their job and even behave like ambulance personnel in their free time, and they find it difficult to separate their professional and personal lives. It seems that they are aware that this is not beneficial, but they feel that they cannot help it because of the public attention. Working in the emergency medical services negatively affects employees’ work-family balance, social life, and their family and parental roles in many ways [45]. Respondents therefore state that social support is extremely important for them to be able to perform their professional work with quality.

Several factors are needed for one to achieve positive well-being, and one of these is satisfaction with one’s sex life [46]. A part of this study also focuses on this otherwise poorly researched topic in the population of ambulance personnel. According to our results, a large number of respondents report that work has a negative effect on their sex life, not only because of fatigue, which is one of the reasons, but also because of the situations occurring at work. In this context, they need the social support of their partners, who they believe need to keep in mind that they are in a relationship with a health worker who is greatly affected by their work.

There is a large body of research on the topic of the impact of work on the health of ambulance personnel, but there are still certain areas that we have identified through this research that require additional, more in-depth research. Future focus should be placed on preventive and health promotion programmes that would reduce the impact of the workplace on the health and well-being of employees, and on raising awareness among policymakers on the importance of preventive and health promotion programmes.

4.1 Limitations

The study was conducted in one of the regional institutes for emergency medicine and, therefore, highlights problems related exclusively to this institute. In further studies, it would be good to extend the research to include other institutes in the country. Moreover, the results of this research could be utilized to design and conduct a quantitiave study. Furthermore, it would be useful to conduct research focusing on the differences between female and male employees, as employees experience the same factors affecting them, but may perceive them differently. Similarly, research should also focus on how work affects older women, especially from the perspective of menopause, still a taboo topic, which could have an impact on employee well-being. Based on the aforementioned research, preventive and health promotion programmes could be implemented in practice in order to improve the well-being of employees and ensure the sustainability of the system.

5 Conclusion

This study attempted to identify the elements that lead to diminished sense of well-being among ambulance personnel, their actual desires, and their suggestions on how to reduce these difficulties. The conclusions of the study can serve as important guidance for the design of preventive measures and educational programmes which could be implemented in emergency service practice. This study identifies and highlights the problems that should be addressed and offers potential solutions that are considered best by those working in emergency services. Raising awareness of the importance of implementing preventive and health promotion programmes, understanding problems through employee opinion, and training are very important tools for preventing problems among employees. Long-term work in the emergency medical services affects the health and satisfaction of employees. In emergency medical services patients come first. However, it is also essential that employees are healthy so that they can give their best and provide the optimal care to patients.

Ethical approval

The research and research method were approved by the Ethics Commission of the Teaching Institute for Emergency Medicine of Istria County (UR: 2163-5-1-70/1/23).

Informed consent

Written informed consent was obtained from all participants.

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Acknowledgments

The authors acknowledge the Teaching Institute of Emergency Medicine of Istria County for permission to conduct the study as well as all research participants for their time and effort.

Funding

The authors report no funding.

References

Sterud

, Hem

, Lau

, Ekeberg

. A comparison of general and ambulance specific stressors: Predictors of job satisfaction and health problems in a nationwide one-year follow-up study of Norwegian ambulance personnel. J Occup Med Toxicol Lond Engl. 2011;6(1):10. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3074526/

Betlehem

, Horvath

, Jeges

, Gondocs

, Nemeth

, Kukla

. How healthy are ambulance personnel in Central Europe? Eval Health Prof. 2014;37(3):394–406. Available from: https://pubmed.ncbi.nlm.nih.gov/23329553/

Costa

. Shift work and health: Current problems and preventive actions. Saf Health Work. 2010;1(2):112–23. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3430894/

Lewis-Schroeder

, Kieran

, Murphy

, Wolff

, Robinson

, Kaufman

. Conceptualization, assessment, and treatment of traumatic stress in first responders: A review of critical issues. Harv Rev Psychiatry. 2018;26(4):216–27. Available from: https://pubmed.ncbi.nlm.nih.gov/29975339/

Cheng

MKF

, Joseph

, Ferguson

. A cognitive behavioral model of first responder posttraumatic stress disorder. J Cogn Psychother. 2018;32(3):184–91. Available from: https://pubmed.ncbi.nlm.nih.gov/32746434/

Petrie

, Milligan-Saville

, Gayed

, Deady

, Phelps

, Dell

. Prevalence of PTSD and common mental disorders amongst ambulancepersonnel: A systematic review and meta-analysis. Soc PsychiatryPsychiatr Epidemiol. 2018;53(9):897–909. Available from: https://www.astss.org.au/wp-content/uploads/2018/07/Petrie2018_Article_PrevalenceOfPTSDAndCommonMenta.pdf

Lawn

, Roberts

, Willis

, Couzner

, Mohammadi

, Goble

. Theeffects of emergency medical service work on the psychological,physical, and social well-being of ambulance personnel: A systematicreview of qualitative research. BMC Psychiatry. 2020;20(1):348. Available from: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-020-02752-4

Paterson

, Sofianopoulos

, Williams

. What paramedics think about when they think about fatigue: Contributing factors. Emerg Med Australas EMA. 2014;26(2):139–44. Available from: https://pubmed.ncbi.nlm.nih.gov/24708002/

Hegg-deloye

, Brassard

, Jauvin

, Prairie

, Larouche

, Poirier

. Current state of knowledge of post-traumatic stress, sleeping problems, obesity and cardiovascular disease in paramedics. Emerg Med J EMJ. 2013;31. Available from: https://pubmed.ncbi.nlm.nih.gov/23314206/

10.

Rippe

. Manual of Lifestyle Medicine. Taylor & Francis Limited; 2021, p. 300. Available from: https://www-taylorfrancis-com-443.web.bisu.edu.cn/books/mono/10.1201/9781003043706/manual-lifestyle-medicine-james-rippe

11.

Anstey

, Tweedie

, Lord

. Qualitative study of Queensland paramedics’ perceived influences on their food and meal choices during shift work. Nutr Diet. 2016;73(1):43–9. https://onlinelibrary-wiley-com-443.web.bisu.edu.cn/doi/10.1111/1747-0080.12237

12.

Supples

, Rivard

, Cash

, Chrzan

, Panchal

, McGinnis

. Barriers to physical activity among emergency medical services professionals. J Phys Act Health. 2021;18(3):304–9. Available from: https://pubmed.ncbi.nlm.nih.gov/33567402/

13.

Macdonald

, Rossiter

, Jensen

. Nutrition and shiftwork:Evaluation of new paramedics’ knowledge and attitudes. Can J DietPract Res Publ Dietit Can Rev Can Prat Rech En DiététiqueUne Publ Diététistes Can. 2013;74:198–201. Available from: https://www.thefreelibrary.com/Nutrition+and+shiftwork%3A+evaluation+of+new+paramedics%27+knowledge+and...-a0352850271

14.

Cash

, Anderson

, Lancaster

, Lu

, Rivard

, Camargo

. Comparing the prevalence of poor sleep and stress metrics in basic versus advanced life support emergency medical services personnel. Prehosp Emerg Care. 2020;24(5):644–56. Available from: https://pubmed.ncbi.nlm.nih.gov/32314941/

15.

Wolkow

, Ferguson

, Aisbett

, Main

. Effects of work-related sleep restriction on acute physiological and psychological stress responses and their interactions: A review among emergency service personnel. Int J Occup Med Environ Health. 2015;28. Available from: https://pubmed.ncbi.nlm.nih.gov/26182918/

16.

Lawn

, Roberts

, Willis

, Couzner

, Mohammadi

, Goble

17.

Gibson

, Brown

. Working with Qualitative Data. 1 edition. London; Thousand Oaks, Calif: SAGE Publications Ltd; 2009, p. 232. Available from: https://www.academia.edu/1243232/Working_with_Qualitative_Data

18.

Kaae

, Traulsen

. Qualitative Methods in Pharmacy Practice Research. In: Babar ZUD, editor. Pharmacy Practice Research Methods [Internet]. Cham: Springer International Publishing; 2015 [cited 2019 Sep 13]. pp. 49-68. Available from: https://doi.org/10.1007/978-3-319-14672-0_4

19.

Bryman

. Social Research Methods. Oxford University Press; 2016, p. 785. Available from:

20.

Sandelovski

. Whatever happened to qualitative description? [Internet]. 2000 [cited 2019 Sep 4]. Available from: https://onlinelibrary-wiley-com-443.web.bisu.edu.cn/doi/abs/10.1002/1098-240X%28200008%2923%3A4%3C334%3A%3AAID-NUR9%3E3.0.CO%3B2-G

21.

Whitehead

, Dahlgren

. Concepts and principles for tackling social inequities in health: 2007. Available from:https://ktpu.kpi.ua/wp-content/uploads/2014/02/social-research-methods-alan-bryman.pdf

22.

Gruber

, Sarajlic Vukovic

, Musovic

, Moravek

, Starcevic

, Martic Biocina

. Migracija hrvatskih liječnika u globalnom kontekstu. Med Flum Med Flum. 2020;56(2):88–96. Available from: https://hrcak.srce.hr/clanak/344590

23.

Moser

, Korstjens

. Series: Practical guidance to qualitative research. Part Sampling, data collection and analysis. Eur J Gen Pract. 2018;24(1):9–18. Available from: https://pubmed.ncbi.nlm.nih.gov/29199486/

24.

Horowitz

, Gerson

. Observation and Interviewing: Options and Choices in Qualitative Research. In: May T, editor. Qualitative Research. London: Sage; 2002. Available from: https://nyuscholars.nyu.edu/en/publications/observation-and-interviewing-options-and-choices-in-qualitative-r

25.

Steen

, The Handbook of Midwifery Research | Wiley [Internet]. Wiley.com. 2011 [cited 2023 Jan 7]. Available from: https://www-wiley-com-s.web.bisu.edu.cn/en-au/The+Handbook+of+Midwifery+Research-p-9781405195102

26.

Gantar

, Vogrinc

. Kvalitativno raziskovanje na pedagoškem področju [Internet]. Univerza v Ljubljani, Pedagoška fakulteta; 2008 [cited 2023 Jan 7]. Available from: https://repozitorij.uni-lj.si/IzpisGradiva.php?id=68053

27.

Okada

, Ishii

, Nakata

, Nakayama

. Occupational stress among Japanese emergency medical technicians: Hyogo Prefecture. Prehospital Disaster Med. 2005;20(2):115–21. Available from: https://pubmed.ncbi.nlm.nih.gov/15898491/

28.

Kim

, Kim

, Ryoo

, Yoo

. Relationship between occupational stress and work-related musculoskeletal disorders in korean male firefighters. Ann Occup Environ Med. 2013;25:9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3923336/

29.

Lad

, Oomen

NMCW

, Callaghan

, Fischer

. Comparing the biomechanical and psychophysical demands imposed on paramedics when using manual and powered stretchers. Appl Ergon. 2018;70:167–74. Available from: https://pubmed.ncbi.nlm.nih.gov/29866307/

30.

Butt

. The Impact of Gurney Design on Ems Personnel. 2009 [cited 2022 Nov 11]; Available from: https://www.academia.edu/29494736/The_Impact_of_Gurney_Design_on_Ems_Personnel

31.

Armstrong

, Ferron

, Taylor

, Mcleod

, Fletcher

, Ee

. Implementing powered stretcher and load systems was a cost effective intervention to reduce the incidence rates of stretcher related injuries in a paramedic service. Appl Ergon. 2017;60:34–42. Available from: https://pubmed.ncbi.nlm.nih.gov/28411738/

32.

Rebak

, Suliga

, Grabowska

, Głuszek

. The prevelance ofmetabolic syndrome on the sample of paramedics. Int J Occup MedEnviron Health. 2018;31(6):741–51. Available from: https://pubmed.ncbi.nlm.nih.gov/30572699/

33.

Petrie

, Milligan-Saville

, Gayed

, Deady

, Phelps

, Dell

. Prevalence of PTSD and common mental disorders amongst ambulance personnel: A systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2018;53(9):897–909. Available from: https://pubmed.ncbi.nlm.nih.gov/29869691/

34.

Mishra

, Goebert

, Char

, Dukes

, Ahmed

. Trauma exposure and symptoms of post-traumatic stress disorder in emergency medical services personnel in Hawaii. Emerg Med J EMJ. 2010;27(9):708–11. Available from: https://pubmed.ncbi.nlm.nih.gov/20466825/

35.

Bennett

, Williams

, Page

, Hood

, Woollard

. Levels of mental health problems among UK emergency ambulance workers. Emerg Med J EMJ. 2004;21(2):235–6. Available from: https://pubmed.ncbi.nlm.nih.gov/14988360/

36.

Alexander

, Klein

. Ambulance personnel and critical incidents: Impact of accident and emergency work on mental health and emotional well-being. Br J Psychiatry J Ment Sci. 2001;178(1):76–81. Available from: https://pubmed.ncbi.nlm.nih.gov/11136215/

37.

Ben-Ezra

, Palgi

, Essar

, Sofer

, Haber

. Acute stresssymptoms, dissociation, and depression among rescue personnel 24hours after the Bet-Yehoshua train crash: The effects of exposure todead bodies. Prehospital Disaster Med. 2008;23(5):461–5. Available from: https://ovc.ojp.gov/sites/g/files/xyckuh226/files/media/document/imp_exposure_to_bodies-508.pdf

38.

Liu

, Wheaton

, Chapman

, Cunningham

, Lu

, Croft

. Prevalence of healthy sleep duration among adults–united states, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(6):137–41. Available from: https://www.cdc.gov/mmwr/volumes/65/wr/mm6506a1.htm

39.

Kuhn

. Circadian rhythm, shift work, and emergency medicine. Ann Emerg Med. 2001;37(1):88–98. Available from: https://pubmed.ncbi.nlm.nih.gov/11145778/

40.

Wang

, Li

, Cui

, Meng

, Zhou

, Xiao

. Sleep duration and riskof coronary heart disease: A systematic review and meta-analysis ofprospective cohort studies. Int J Cardiol. 2016;219:231–9. Available from: https://www.internationaljournalofcardiology.com/article/S0167-5273(16)31033-6/fulltext

41.

Wong

, Wong

MCS

, Wong

SYS

, Lee

. The association between shift duty and abnormal eating behavior among nurses working in a major hospital: A cross-sectional study. Int J Nurs Stud. 2010;47(8):1021–7. Available from: https://pubmed.ncbi.nlm.nih.gov/20116059/

42.

Sheridan

. Paramedic health status, fitness and physical tasks: A review of the literature. Australas J Paramed [Internet]. 2019 Mar 30 [cited 2022 Oct 13];16. Available from: https://ajp.paramedics.org/index.php/ajp/article/view/580

43.

Buzga

, Zdenek

, Buzgová

. State of physical healthand fitness of paramedics in Czech republic. Kärntner Bot. 2015;22:205–2012. Available from: https://www.researchgate.net/publication/274715294_State_of_physical_health_and_fitness_of_paramedics_in_Czech_republic

44.

Dopelt

, Wacht

, Strugo

, Miller

, Kushnir

. Factors that affect Israeli paramedics’ decision to quit the profession: A mixed methods study. Isr J Health Policy Res. 2019;8(1):78. Available from: https://pubmed.ncbi.nlm.nih.gov/31672166/

45.

Anderson

. The impact of paramedic shift work on the family system: A literature review. Br Paramed J. 2019;3(4):43. Available from: https://www.paramedicpractice.com/features/article/the-impact-of-paramedic-shift-work-on-the-family-system-a-literature-review

46.

Stephenson

, Meston

. The conditional importance of sex:Exploring the association between sexual well-being and lifesatisfaction. J Sex Marital Ther. 2015;41(1):25–38. Available from: https://www.researchgate.net/publication/259204186_The_Conditional_Importance_of_Sex_Exploring_the_Association_Between_Sexual_Well-Being_and_Life_Satisfaction