The Coronavirus Disease 2019 (COVID-19) has had a greater impact on the world than many would have ever expected, and in all aspects of our life, whether economically, environmentally, socially, physically, or mentally. The latter has been especially felt among frontline clinicians, who have been under extremely high pressure, dealing with a significantly higher patient load and stressful situations over a prolonged period of time and with a high number of uncertainties. In the UK, up to August 2020, there had been a noticeable increase in the number of emergency ambulance and non-urgent (NHS 111) calls, though fewer emergency department visits due to lockdowns (Flynn et al, 2020). This put frontline ambulance paramedics at an increased risk of exposure to the virus and high workload pressure.
Mental health issues among health professionals is not a new issue by any means (Bennett et al, 2004). However, the last 2 years has been an unprecedented period of time for everyone. Following the unquantifiable Brexit exodus among European National Health Service Staff (Alinier, 2019; Dalingwater, 2019), COVID-19 has added yet more pressure on the already stretched prehospital healthcare workforce. From the beginning, the pandemic has had profound effects on how clinicians worked and lived their lives, with reports of many sleeping in their car, in the hospital, or in hotel rooms between shifts to minimise the risk of contaminating family members (Viswanathan et al, 2020; Al Amiry and Maguire, 2021). Although, a clear effect on the mental health of the general population in all sectors has been noticed (Flynn et al, 2020), it is even further pronounced among the healthcare workforce (Xiong et al, 2020; Khan et al, 2022).
For paramedic staff, it is likely at an even higher level due to the often difficult working circumstances, the uncontrollable environments within which they operate, and their direct exposure to patients sometimes in critical condition. They are known to be at a high risk of burnout (Crowe et al, 2018). Although mental health support is commonly made available ‘in-house’ to clinicians, they often shy away from it as they may not trust the system and be afraid of the potential impact it may have on their career prospects within the organisation. Perhaps a more subtle, welcoming and supportive approach should be put in place to mitigate the effects of high stress levels experienced by prehospital care clinicians.
A recent study conducted in Qatar using an online survey with a validated tool circulated among paramedic staff revealed that the staff's level of stress increased from moderate to severe as a result of the COVID-19 pandemic (p<0.05) (Al Barbari et al, 2022a). There has been an apparent downward spiral effect severely affecting the paramedic profession for many years in the UK (Wankhade, 2018). Unfortunately, the higher the workload pressure on staff, the more likely they are to resign due to burnout. Furthermore, the more they decide to leave the profession, the higher the pressure becomes for those who stay!
The other supportive approach to deal with stress relates to the coping strategies that can be adopted. Based on the same population of paramedics working in Qatar, noticeable and concerning effects of the pandemic were found using a validated tool about how they manage their work-related stress (Al Barbari et al, 2022b). Likely as a result of the COVID-19 infection control measures put in place and extended working hours, like everywhere else, paramedics were hampered in the practice of their usual coping mechanisms, which generally included group social activities group social activities such as team-based sports and religious gatherings. The study also highlighted that the paramedic staff coping mechanisms were associated with ethnicity and cultural preferences (Al Barbari et al, 2022b; 2022c). A very particular and contextual aspect to consider is that Qatar's paramedic workforce is constituted of staff from several nationalities nearly equally represented in numbers (Gangaram et al, 2017). About 21% fewer study participants reported using coping strategies during the pandemic than they did before. This certainly further increased their overall risk of burnout and negatively affected their mental health. A scoping review by Shaukat et al (2020), based on 10 shortlisted articles, identified five studies that assessed the mental health of healthcare workers, nearly all emerging from China. Their findings related mainly to the reported anxiety, depression, and insomnia of healthcare workers, especially among those with a frontline role. These issues are not totally new to the COVID-19 era—especially among paramedics—and potential solutions have already been proposed (Dodd, 2017). According to more recent findings from Shaukat et al (2020), key recommendations to reduce morbidity and mortality among healthcare workers, alongside strategies to reduce chances of COVID-19 infection, are shorter shift lengths and mechanisms for mental health support. These however remain challenging to implement and manage from a scheduling point of view with a limited and stretched workforce. The COVID-19 pandemic has only had a compounding effect on the existing issues and there is unfortunately still no visible light at the end of the tunnel. Because of this, mutual support and good teamwork remain key ingredients to providing high-quality prehospital care, as well as inspiring future generations to join the profession—which despite its many challenges is highly fulfilling.