In this study, Norwegian ambulance personnel showed a prevalence of manifest posttraumatic stress disorder symptoms of 5 %, while 8.6 % reported moderate to severe depression and 2.9 % presented moderate to severe symptoms of general anxiety. Over half of the respondents had experienced threats or aggression towards themselves or colleagues in the past 12 months. We observed increased posttraumatic stress symptoms in workers who were unmarried/ no partner, or those reporting no access to peer support. Moreover, exposure to ambulance accidents or feelings of inadequacy towards patients regarding treatment errors was also associated with increased reporting of posttraumatic stress symptoms in this study. The vast majority of respondents reported personal growth as a consequence of their work experiences.
The reported levels of posttraumatic symptoms in this study were lower than recent systematic reviews of PTSD in ambulance personnel, where the prevalence was quoted at 10.2 % and 11 % respectively [9, 19]. However, the current results are more in alignment with other European surveys conducted in cohorts that may be culturally similar to Norwegian EMS personnel, with one German study reporting a positive PTSD screening of 5.4 %, and in Switzerland with 4.3% [20, 21].
The current study found that PTSD among EMS workers was more common among men than what is generally reported in the Norwegian general adult male population. A recent study of Norwegian adults described a point prevalence of PTSD of 3.8 % (men) and 8.5 % (women), while the current study reported 4.7 % men and 5.3 % women . Of note, our study showed no significant difference in PTSD prevalence with regards to biological sex, professional background, nor percentage of employment. This result deviates from findings in the Norwegian general population, and the discrepancy merits further studies.
The relative low prevalence of reported PTSD in this study may have several reasons. First, EMS in Norway has become increasingly professionalized, with focus on selection, training and further education. Almost half of respondents in this study were either qualified nurses or paramedics, and more than 80 % were in full time positions. Studies among fire fighters have shown increased PTSD among part-time versus full-time employees . There has also been increasing focus on mental wellbeing within EMS, furthering knowledge and possibly lowering the threshold to seek help. In our study population, 47.2 % of participants were women. A study of Norwegian ambulance personnel performed in 2005 included 23.2 % women in comparison . It is possible, that an increasing female proportion in Norwegian EMS has contributed to a culture of more openness and acceptance, as opposed to more male dominated work cultures. Studies have also shown, that women in the military or working as first responders show no higher rates of PTSD compared to men. This can possibly be explained by selection [9, 20, 25, 26]. Women in this study had a lower average age compared to men, and this may also explain the lower age of women with positive PTSD screening found in this study.
A recent Norwegian study showed a prevalence of self-diagnosed current depression at 8.1 %, higher for women (9.8%) than men (6.1%), and another similar Norwegian study reported anxiety at 6.6 % [27, 28]. This was comparable to the current study, where 8.6 % reported depression (men 9.4 %/ women 7.5 %), whereas anxiety prevalence was considerably lower, at 2.9 %. We found a positive correlation between severity of depression and anxiety, and increased PTSS scores. This finding is important, because it indicates that mental health issues and PTSS are associated with each other, although this study does not clarify a cause and effect relationship between the two. A study of Norwegian ambulance personnel by Sterud et al reported serious suicidal ideation in 10.4 % of the study population, describing a strong relationship with depression symptoms . In addition they reported that more than half of this group had not sought professional help, emphasizing the importance of appropriate support and guidance within the service.
The implementation of preventative measures in the work environment may improve the mental wellbeing of employees . In this study, more than 90 % of participants reported having access to a peer support programme, with over a third having utilized it one time or another. In this study there was an association between increased post traumatic stress symptoms and reporting having no access to peer support, and the same applied to respondents who were not in a marital-/ partner relationship. Likewise, we observed similar associations between post traumatic deprecation (negative emotional growth) and respondents with no partners or lacking peer support, emphasizing the positive effect of social support on mental wellbeing, mitigating PTSD and facilitating post traumatic growth, as reported in other studies [31, 32].
This study indicates that Norwegian EMS personnel are regularly exposed to potentially traumatic events. Traditionally, traumatic stress has been understood as relating to life-threatening events and subsequent fear dysregulation, and it may be more intuitive to associate exposure to violent events and threats with increased stress, which we also observed in this survey. However, in many traumatic situations, peritraumatic fear may not be present, and a physical threat may not be the most stressful part of the incident [33, 34]. Accordingly, recent studies have distinguished between danger-based and non-danger-based stressors . In the context of the current study, this may help explain why perceptions of inadequacy and even shame, also committing errors, may lead to increased posttraumatic stress reactions.
Resilience in this context can be described as the ability of an individual to adjust to challenges and influences which potentially may be psychological harmful . That more than 90 % of our sample did not report any mental health complaints, despite the substantial degree of exposure to traumatic stressors, indicates high levels of resilience in the study cohort. This may be due to training and preparedness for the most commonly encountered stressors, and the efficacy of existing peer support programs. Moreover, we included the Posttraumatic change scale (PTCS) in this survey, and over three quarters of participants reported experiencing growth after exposure to experiences. The concept of “posttraumatic growth” encompasses more than a return to normal function after a period of distress, but indicates “positive psychological changes experienced as a result of the struggle with highly challenging life circumstances” . This model provides a positive outlook on how personnel working in demanding professions can learn and develop emotionally from distressing experiences, even if such events precipitate a period of psychological suffering [15, 38].
This study has several limitations. The response rate was 46 %, which means that findings should be interpreted with caution. Missing answers could definitely influence results, and there may be a risk that the most troubled by traumatic experiences did not answer our survey. However, response rates have been described as a typical challenge in studies of related occupational groups . In similar studies of ambulance personnel, response rates have varied greatly, illustrated by the following reported rates in studies: 5 %, 7 %, 26 %, 32 %, 41 %, 72 % and 77 % [19, 20, 29, 38–41]. Regarding gender differences, the ratio of those invited to participate was 53 % men and 47 % women, virtually identical to the response ratio. The study incorporated three different health trusts, with varying geography and both urban and rural demographics, supporting the applicability of the findings as being representative of a Norwegian ambulance population. Due to the nature of the study, a self-reported survey carries the risk of both reporting bias and recall bias. Reporting bias may however be mitigated by the use of questions which are not open-ended, and the anonymity of respondents.
Validated tests were applied to measure posttraumatic stress, posttraumatic growth, depression and anxiety. This study can only give an indication of the prevalence of these serious conditions, and self-reported questionnaires cannot compare to diagnostic interviews in this respect . In addition, this survey was performed among current operative personnel. Therefore, we have no data on personnel on prolonged leave, those who have retired or left the service, or personnel now working in administrative positions, irrespective of the reason for changing their employment status. It is possible to assume, that personnel who are struggling to cope in an operative setting, whatever the reason, may choose to move on, or work in a different capacity, thereby distorting the prevalence of certain conditions in our data.