Improving Management of PTSD Among Ambulance Staff

This literature review explores ways to improve the management of Post-Traumatic Stress Disorder (PTSD) among frontline staff in the ambulance service. It discusses the impact of PTSD on staff well-being, the symptoms of PTSD, and the need for early interventions and support. The review also highlights the importance of training, teamwork, and organizational support in managing PTSD effectively.

HOW TO IMPROVE THE MANAGEMENT OF POST-TRAUMATIC STRESS
DISORDER (PTSD) AMONGST FRONTLINE STAFF IN THE AMBULANCE SERVICE
1
How to Improve the Management of Post-Traumatic Stress Disorder (PTSD)
Amongst Frontline Staff in the Ambulance Service
A Review of Literature

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Contents
Glossary.................................................................................................................................................2
Introduction...........................................................................................................................................2
Table 1 - Sickness absence data ....................................................................................................3
GANT chart........................................................................................................................................5
Literature Review..................................................................................................................................5
Methodology.....................................................................................................................................5
Search Strategy................................................................................................................................16
Results.............................................................................................................................................16
PICO Table....................................................................................................................................21
Analysis and Discussion...................................................................................................................22
Conclusion.......................................................................................................................................24
References...........................................................................................................................................27
Glossary
Locality –
PTSD -
Introduction
I am currently employed as a Locality Manager working for an Ambulance Service in
the NHS Trust. The details of the NHS Trust will be kept anonymous to comply with
the Data Protection Act 2018. I have been in my current post for the last six years. I
am also a registered paramedic and have gained valuable experience in the pre-
hospital environment. One of the key responsibilities of my job role is to manage
sickness within my locality (Britnell and et.al., 2017). My locality covers an estimated
population of 425,500 which encompasses small towns and villages. I am currently
managing 150 staff within my locality. Over the years, I have dealt with an increase
in absences relating to depression, Post-Traumatic Stress Disorder (PTSD) and
stress in the workplace. According to the Mental Health Foundation (2020), in the UK
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about 70 million days are lost in the workplace each year due to staff presenting with
anxiety, stress, and more complex mental health conditions such as depression and
bipolar disorder.
I have chosen to undertake a literature review of PTSD, which will enhance my
knowledge and understanding of the condition in order to help me to recognize the
signs and symptoms and provide ongoing staff support (Alharbi and et.al, 2020). It
can be said that PTSD can require implementing early interventions that can help in
reducing the overall rates of addmissions to the hospitals.
There has been an increase in sickness within my locality. This is shown in the pie
chart and graph below (Table 1). This indicates that 41.1% of staff sickness is due to
anxiety, stress or depression. Empactis (2020) and Mildenhall (2013) also
emphasizes that frontline ambulance staffs’ sickness levels are far greater than
health care workers in other NHS sectors.
Table 1 - Sickness absence data
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According to NHS Choices (2018), PTSD results from a prolonged traumatic,
frightening or distressing event. This definition is also supported by Jonathan et al.
(2013), who mentions that PTSD can occur following a traumatic event. Early
symptoms of PTSD are evident during the first month after the occurrence of the
event. However, in some cases, trauma can prolong the signs up to months or even
years (NHS Choices, 2018). PTSD can present in many different forms, for instance,
there are four categories of symptoms of PTSD (Jonathan et al. 2013). Firstly
intrusion; examples include disturbing dreams or frequent flashbacks of the event
occurrence. Secondly, avoidance is being reminded of the event being traumatizing;
examples include places, people, objects, and situations that may remind one of
distressing memories (Cordova, Riba and Spiegel, 2017). Thirdly, alterations in
cognition and mood; they cannot recall important aspects of the traumatic event,
leading to negative thoughts and feelings, for instance, blaming yourself and others,
fear, horror, anger, and guilt. Fourthly, alterations in reactivity symptoms and arousal
may include irritability or inability to sleep (Jonathan et al. 2013). Other examples are
concentrating or having an outburst and behaving recklessly.
Some circumstances that could lead to PTSD are a severe accident, domestic
abuse, exposure to a traumatic event and child abuse. NHS Choices (2018) states
another example of PTSD is being present in a war or conflict. Historically during
World War I, PTSD has been referred to as ‘Shell Shock’ and after World War II
renamed ‘Combat Fatigue’ (Felix 2020). One of the reasons there is an increase in
the absence of sickness relating to PTSD is working in a pre-hospital environment
(Dodd 2017). He argues that the pre-hospital climate has changed over the years,
putting additional pressure on frontline ambulance staff in clinical decision making in
pressurized environments promptly. These factors, combined with work and
unpredictable shift patterns and training engagements, including daily stress like
health or relationship breakdown, contribute to and negatively impact performance,
motivation, and general well-being (Ashman, Rigg and Moore, 2020), who suggests
a continuous change in demand and workload. Moreover, it can leave staff feeling
overwhelmed and unable to talk to their peers or senior staff, leading to emotional
fatigue, burnout, anxiety, depression, or PTSD. Therefore we must build welfare into
the everyday working practice.
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An online survey was carried out by Mind (2016), a mental health charity of over
1600 volunteers. From police, fire, and ambulance service revealed nine in ten, 92%
of respondents had been victims of stress, low mood, and lack proper mental health
at certain point in their careers while working in the unit of emergency services. In
contrast, 62% had experienced mental health problems varying from depression,
anxiety disorders, OCD, PTSD. Furthermore statistical data suggests 2 in 5 had
been prescribed medication such as antidepressants or help them sleep. 5% had
attempted to take their own life (Baqai, 2020). Over half, 55%, had sought medical
intervention, and 6% were admitted to hospital.
I will undertake a literature review to examine Post-traumatic Stress Disorder
(PTSD), problems in mental health amongst frontline staff in the Ambulance service.
This will enable me to strategically manage those staff who present with symptoms
of PTSD in my work place (Elms and et.al., 2019). Early recognition of signs and
symptoms could result in early interventions of management of the condition which
will enable me to refer earlier for counselling or Occupational Health, to minimise the
impact on the wellbeing of my staff which could potentially reduce the impact on day
absence.
The onerous also lies with an employer in insuring support is available for staff
presenting with PTSD, especially those who have been affected by attending
traumatic incidents. I am in a position to make change, by undertaking a literature
review I will have gained a better understanding and knowledge to implement
changes in my practice.
GANT chart
Literature Review
Methodology
There are many studies that have been conducted and their results show that
there is a significant association between mental health as well as various
occupational factors among ambulance personnel. Although, there are not a lot of
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studies that have been undertaken on this particular topic (El-Solh and et.al., 2017).
Ambulance personnel’s physical as well as emotional well being is a very important
issue that has to be kept in mind. It is important to adopt various measures that can
help in improving the Management of Post-Traumatic Stress Disorder (PTSD)
Amongst Frontline Staff in the Ambulance Service. PTSD can be referred to as a
mental health condition that is mainly triggered by a triggered event. Symptoms of
the same can include nightmares, flashbacks and severe anxiety. Ambulance
workers have a very tough job and it is important to make sure that they do not deal
with a lot of trauma. In the UK, it has been found that ambulance workers have
displayed higher rate of early retirement (Forbes and et.al., 2019). They have a more
tough personality because they have to deal with various situations from time to
time. Ambulance workers are emergency medical personnel who work to provide
medical care. If the condition is not managed properly, it can pose serious
challenges to the mental health of the frontline workers. There are different critical
incidents that can impact the overall mental health of ambulance workers. It has
been found that the job satisfaction level among people who provide care to people
is high. This is because they consider providing care for others personally gratifying.
They can face emotional difficulties as well, when it comes to less
experienced staff members (Burruss, Holt and Wall-Parker, 2018). This view is also
supported by Mildenhall (2019). It can be said that the level of experience among
frontline workers in ambulance service also plays a very important role. Due to this,
the managers of the organization can be less alert about their individual needs as
well as early warning signs, if there are any. It can be said that this type of job
requires proper management for the long run. But the senior staff members are more
likely to report emotional problems related to their traumatic work as compared to
newly hired people who are less experienced (Naushad and et.al., 2019).
Ambulance workers deal with different types of incidents and some of them can be
more traumatic than others. And regular exposure to such incidents can lead to
affecting the overall well being of the people. It is important to provide effective
training to the front-line workers so that they are able to cope with a sudden
uncertain situation (Haagen and et.al., 2017). A number of studies have emphasized
on the importance of training and development to these people. The ambulance
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workers should support each other at all times so that the situation can be controlled
and handled in an effective manner.
It can be said that hardiness is one of the most popular concepts in this is that
of hardiness. Emergency workers are considered to be hardier than others due to
the nature of their job. They may exert an effect in numerous methods, which include
via an adaptive appraisal of events, or via the facilitation of other adaptive methods
of coping such as exercising, weight loss program and sleep. Similarly, this take a
look at cannot determine whether or not those traits are immutable capabilities of the
personality or whether or not they may be evolved through revel in and training
(Carleton and et.al., 2018). The identification of character features that serve to
defend people who supply health care against rigours of their work additionally
poses a predicament, however, because those functions might not always be
satisfactory applicable to the transport of that carrier (Hori and Kim, 2019). The
safety of frontline emergency personnel also stays a prime issue. The authorities has
come under intense complaint for its tardy reaction towards mass testing for COVID-
19 – both for frontline responders and the network. There has also been increasingly
healthcare workforce demise due to lack of private defensive system, in conjunction
with reviews of group of workers “limiting work” because of such shortages.
PTSD can have an intense impact on their thoughts as well as feelings and
therefore, it is important to adopt appropriate strategies to manage the same. If not
managed properly, it can lead to serious problems. It is important to keep a check on
the same. As a result, the situation can be handled in a better manner (Chatzea and
et.al., 2018). on the other hand, not being able to manage the situation effectively
can lead to memory problems, poor relationship with their co-workers, anxiety and
trouble in staying awake. In context to the workers should ask for help if they think
that this will help them out in an effective manner. Otherwise, their family members
also have to suffer from the same.
Therefore, it can be said that the ambulance service has a duty to care for
people in times of emergencies. Any person can experience a traumatic experience
during their lifetime and at any point of time. But those who work in the frontline of
ambulance service are usually exposed to different traumatic experiences from time
to time. Their work is very important and proper management should be done
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(Kazour and et.al., 2017). Traumatic distress may be skilled as having intrusive
reminiscences of the incident, perhaps isolating oneself, reducing off pals and circle
of relatives, having difficulty sound asleep and/or regulating emotions. There are
many one-of-a-kind ways wherein intellectual and physical health may be affected.
Several elements present inside the everyday paintings of ambulance employees,
and in how organisational management acknowledge and respond, had been
diagnosed as being significant and contributing to mental health and well-being, or
growing the threat for growing situations including PTSD, despair, and anxiety
(Robertson, 2019). Ambulance employees articulated their properly-being wishes
across four key areas: organisational guide; informal assist; use of humour; and man
or woman mechanisms to cope which includes detachment and external supports.
Thus, the symptoms should be dealt with effectively and must be identified from time
to time.
Front line workers in ambulance services may experience traumatic distress
in the form of intrusive memories of the incident that they have experienced (Chirico,
Nucera and Magnavita, 2021). As a result, they might isolate themselves or cut off
from friends as well as family members. They might also experience difficulty in
sleeping and even regulating their emotions. Studies have shown that frontline
workers in ambulance service have been very disturbed by an emergency call that
they had attended (Koek and et.al., 2019). It is very important for the management of
a health organization to improve the way in which PTSD among front line workers in
ambulance service is managed. This is because they display a high level of
symptoms PTSD. It has also been observed that PTSD is most commonly linked
with mental health outcomes such as anxiety as well as depression. If the front-line
workers do not process the memories that are associated with processing memories
associated with the traumatic experiences that they have encountered can lead to
long-term distress and not being able to respond normally. Dealing with acutely
unwell humans is surely disturbing (Civilotti, Di Fini and Maran, 2021). Some
sufferers will unavoidably have a terrible outcome and there may be the possibility of
self-recrimination amongst emergency staff. Studies have suggested an incidence of
put up-annoying stress disorder Emergency ambulance employees are susceptible
to mental distress in both the quick-time period and long term. While emergency
work may be rewarding, personnel are also required to cope with some potentially
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traumatising conditions (Roh, Kim and Kim, 2020). By adopting appropriate
measures, PTSD among ambulance workers can be managed effectively and
without any negative impact on their overall mental health.
Neuropsychology is a branch that has helped in developing an in-depth
understanding about of why and how PTSD occurs. This has further helped in
developing knowledge about how can the mental health of the people in the frontline
can be protected. This is because they experience events that are distressing more
than as compared to anyone else (Lewis and et.al., 2020). One of the ways in which
this situation can be managed is by putting the things into context for them and
defining meaning for the event so that the same can be processed in their long-term
memory. This will enable them to move on from the same and live a healthy life. In
order to process the event into the minds of frontline workers in the ambulance
service is to talk about the same with them (Craig and et.al., 2020). Providing a
narrative and talking to them about what happened has been found to help them and
normalize their feelings post experience of the incident. These can include sadness,
guilt, anger or even blame. In order to have a brief conversation about the incident,
the front-line ambulance workers can include providing them with sufficient amount
of time so that they can process the incident and when they are comfortable in
speaking about the same, they should be allowed to do so (Saberian and et.al.,
2020). But if they will not be provided with adequate time, they will feel neglected
and this can lead to an increased level of depression as well as anxiety.
Ambulance crews and paramedics have encounter incidences on a regular
basis in comparison to a normal person who may only experience such an incident
only once in their lifetime. People working in ambulance service are expected to
respond to different catastrophic events (Murphy and et.al., 2017). They always work
under the pressure of performing and desire to save the lives of people. It is
important to manage PTSD in an effective manner among ambulance workers.
There are cases wherein it has been observed that they display some of the
symptoms such as anxiety, depression, obsessive compulsive disorder etc. Among
these PTSD or Post-traumatic stress disorder and bipolar disorder are among the
main symptoms (Samson and Shvartzman, 2018). Mental health should always be a
priority as high levels of stress and depression can lead to an increase in the overall
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mental health problems (Dale, 2019). There can be different causes that can affect
the mental health of the paramedics. These can include changing shift patterns, long
hours, excessive workloads, pressure from the management and exposure to
trauma. If the physical health of the ambulance worker is not proper, they will not be
able to deal with day-to-day experiences. Studies have shown that people working in
ambulance services believe that they will be treated negatively (Orsolini and et.al.,
2019). Talking about mental health has become very important today because this
helps in encouraging the medical staff to deal with the issues in an effective manner.
Generally, people are not comfortable in talking about their mental health at work.
But people who are involved in paramedics or ambulance services, have to make
sure that they are mentally fit so that they can perform their day-to-day tasks in an
effective manner.
Ambulance service workers might feel that if they talk about their mental
health, they may seem weak or not being able to cope with the daily events of life.
They may not be aware that by talking about their thoughts, they can actually
contribute to the workplace in an effective manner (Dunkley, 2018). Therefore, in
order to manage PTSD among ambulance service workers effectively, they should
be provided with a positive and healthy working environment. The employees should
feel comfortable in expressing their concerns to their leaders and this is very
important. There are cases wherein some of the paramedics are not confident and
therefore, there is a need to ensure that they are able to handle or deal with the
situation in an effective manner. communication plays a major role in the field of
healthcare (Sheehan, Brent and Deasy, 2020). A lack of confidence can mean that
the paramedics are not able to communicate their mental health issues effectively. It
is important for the employees to come up and speak about the issues that they are
dealing with (Phelps and et.al., 2018). The employers should focus 0on creating an
environment wherein workers in the ambulance service have an access to additional
support whenever they are in need. This will make the employers aware of the
problems if there are any and also minimise further issues.
It is a known fact that ambulance personnel are the most vulnerable to
displaying the different symptoms of PTSD. Post-traumatic stress disorder is not a
new concept and has been studied by many researchers previously. But over the
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years its impact has become visible on the people (Ebadi, Froutan and Malekzadeh,
2019). The symptoms of disorder to generally displayed by people who are involved
in stressful jobs such as workers within the ambulance service. PTSD can be defined
as a type of disorder to anxiety problem that develops after some people experience
extremely traumatic events. This can include crime, a natural disaster or even an
accident. Such people may relive the experience through intrusive memories,
nightmares and flashbacks (Snowdon, 2021). Thus, it is important to make sure that
anything that reminds them of these experiences must be eliminated because it can
lead to making them depressed, anxious and also make it difficult for them to deal
with their day-to-day life (Regel and Joseph, 2017). There is no robust research
conducted in this area to identify the different levels of PTSD among ambulance
personnel. Therefore, it can be said that the factors determining the impact of PTSD
on emergency workers can depend on various factors such as cultural or
geographical differences. There are different measures that can be adopted in order
to deal with the mental health of the ambulance personnel. It must be ensured that
they have people to talk and communicate their thoughts about an experience. It is
very difficult for the frontline workers to maintain a balance because they have to
work across multiple shifts.
Therefore, they should be allowed to take some time off and maintain a
balance in their lives (Storey, Kimble and Holbert, 2021). This can include spending
time with their friends and families, relaxation, sports etc. Also, exercise is a great
way to manage all of the stress and calm the mind. The ambulance workers should
be trained in such a manner that they are able to ask for help in extreme situations
and not shy away from doing so. The condition of PTSD has three pre-dominant
areas such as hyper-arousal, which involves irritability, or mood swings and
sometimes difficulty in sleeping (Goodyear-Brown, 2019). The second area is re-
experience, and in this situation the individual recreates the incident which is almost
similar to reliving the whole experience. The last area is avoidance, in which there
can be a sudden reduction in the motivation level and reduced display of passion
towards others. They keep feeling associated with the event and the person is not
willing to use the prescribed medication as well. The IES can be referred to as a
scale that is used to measure the areas that involve disturbing thoughts such as
flashbacks and nightmares. Using this scale helps in providing better treatment to
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the affected person properly (Shalev, Liberzon and Marmar, 2017). As compared to
other emergency workers, ambulance workers have displayed higher instances of
PTSD. Also, they display stronger symptoms of the condition as compared to
firefighters as well as those working in military. The general perception of the people
who work in the ambulance services is that they have resilient and tough
personalities and that they are able to deal with trauma.
People who are resilient and have tough personalities, develop their own
strategies to deal with such situations. While managing the workers in ambulance
services, the gender difference should be kept in mind (Greinacher and et.al., 2019).
There are studies which show that females are more susceptible to developing
PTSD as compared to males. But in the respective profession, due to its intense
work nature, both genders are susceptible to developing the Post-traumatic stress
disorder. Males who have been into the profession of ambulance services for a long
period of time tend to develop symptoms of PTSD (Turgoose, Ashwick and Murphy,
2018). It can be said that a repeated exposure to trauma can make the ambulance
workers to the risk of developing PTSD symptoms. By providing effective support,
the high risk of developing the disorder. Not only this, equal focus should be laid on
treating PTSD as long as the personnel are in this career. Acute PTSD can be easy
to treat but chronic PTSD is severe and includes factors such as the severity of the
trauma that is experienced, previous personal experiences and the overall education
of the personnel through schooling (Tehrani, 2019). Apart from this, while managing
the disorder, it is also important to keep in mind the prolonged illness as well as
other complications such as depression, anxiety, self-harm and addiction to
medications (Hichisson and Corkery, 2020). Thus, a system should be developed
wherein different ambulance workers should be assigned their tasks based on
different rotational shifts. This is important because it can help in diverting their mind
and allows them to do their jobs in an effective manner.
By implementing job rotation effectively while dealing with mental issues, the
staff motivation as well as their level of job satisfaction can be increased. Therefore,
it can be said that job rotation is a great way to help people who are dealing with
PTSD to divert their minds and that they are able to spend time away from the
trauma of an experience (Theleritis and et.al., 2020). The role of frontline ambulance
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workers has developed to a great extent in the recent years. Pre-hospital care and
management has advanced throughout the decades considerably and this has also
affected the overall level of mental health of the frontline workers. There are different
factors that can lead to an increase int e overall pressure on the mind (Wickersham
and et.al., 2019). If one of the ambulance service workers is dealing with Post
traumatic stress disorder, it can also affect their colleagues to a great extent. This
can have a negative impact on their minds and make it difficult for them to continue
their job effectively along with other issues such as anxiety as well as depression.
Although many intellectual fitness situations share comparable signs and signs and
symptoms, PTSD has several key signs and symptoms which set it apart from
greater commonplace situations. These similarities can make an correct diagnosis
difficult, by using confusing the overall clinical image. These thoughts by way of
suggesting that due to similarities to, for instance psychotic indicators, PTSD can
frequently be misdiagnosed causing delays and problems with the ideal remedy plan
provided. This is, in part, because of the shortage of medical data available to
correctly differentiate the two, that is considerable as treatment for psychotic
conditions such as schizophrenic spectrum ailment or bipolar disorder and PTSD are
fundamentally exceptional (Treleaven, 2018).
It is extremely important to opt for different measures that can help in
eliminating the negative impact of the trauma on the minds of the ambulance
workers. A key imperative for any emergency provider is to broaden techniques for
each the prevention and remedy of the full-size levels of mental health problems
associated with emergency work. Such interventions want to recollect each the
severity and importance of the hassle (Yatham and et.al., 2018). This may
additionally require great innovation, especially as the efficacy of some preventive
techniques has been notably challenged. In the case of PTSD, for instance, there
are regular findings that critical incident debriefing, a widely used preventive remedy,
appears to compound in place of ameliorate the condition. A number of remedy and
prevention techniques may consequently be want to be recognized for each of the
recognized problems (Hruska and Barduhn, 2021). In addition, as wider
organisational elements can also be implicated within the aetiology of PTSD and
temper disorders on this population, consideration have to accept to how
organisational elements contribute to stages of emotional distress, and be blanketed
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in any preventive approach. Whatever techniques are used, they want to be simple
and realistic enough to be relevant to big numbers of workers.
Therefore, other measures that can help in the management and treatment of
PTSD include teaching the frontline workers to deal with their symptoms of the
disorder, helping them to think in a better manner and responding to the difficult
situations in an effective manner. also, there are different types of therapies that can
be adopted for the treatment of the same. For instance, cognitive therapy helps in
recognizing the different ways of thinking so that negative thoughts can be handled
effectively (Wickersham and et.al., 2019). Exposure therapy is another type of
therapy that helps in facing the situation in a much more effective manner. this type
of therapy is particularly helpful when a person is dealing with nightmares as well as
flashbacks. Apart from this, medications can also be used such as antidepressants,
anti-anxiety medications and so in. PTSD adjustments the body's response to stress.
It influences the pressure hormones and chemicals that carry statistics among the
nerves (Vagni and et.al., 2020). People who've suffered early life abuse or other
previous stressful reviews are probably to develop the ailment, on occasion months
or years after the trauma.
CBT is a kind of psychotherapy that has continuously been observed to be the
simplest remedy of PTSD each inside the quick term and the long time. CBT for
PTSD is trauma-targeted, that means the trauma event(s) are the center of the
treatment. It makes a speciality of identifying, understanding, and converting
wondering and conduct patterns (Hutchinson, Forshaw and Poole, 2020). As the
most of the evidence for developing PTSD is linked with long-term service within this
field, in order to reduce its impact job rotation should be considered (Waltman,
Shearer and Moore, 2018). CBT is an active treatment involved the affected person
to engage in and out of doors of weekly appointments and learn abilties to be applied
to their signs. The talents learned all through remedy classes are practiced
repeatedly and assist support symptom improvement. CBT remedies historically
occur over 12 to sixteen weeks. This kind of intervention helps human beings face
and control their fears by means of exposing them to the trauma memory they review
inside the context of a secure surroundings (Britnell and et.al., 2017). Exposure can
use mental imagery, writing, or visits to places or people that remind them of their
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trauma. Virtual truth (creating a digital environment to resemble the traumatic
occasion) can also be used to show the man or woman to the environment that
includes the feared situation. Virtual fact, like other publicity techniques can help in
exposures for treatment for PTSD when the era is to be had (Varker and et.al.,
2018). Regardless of the approach of exposure, a person is frequently regularly
exposed to the trauma to help them grow to be less touchy over the years.
One of the key things for any emergency service is to ensure the development
of strategies for the treatment as well as prevention of PTSD as well as other mental
health issues that can impact the overall thought process of the emergency workers
to a great extent. It is important for these interventions to take into account both the
magnitude as well as the severity of the problem. A considerable level of innovation
may be required for dealing with these problems (Ben‐Ezra and et.al., 2018). This
will help in dealing with the problem in a much more effective manner. In case of
PTSD among ambulance workers, it has been found that they display different
symptoms of the disorder (Wild and et.al., 2020). Treatment and prevention
approaches can also be used in order to manage the disorder among frontline
workers in ambulance service. Ambulance workers who are dealing with PTSD, have
to be able to speak up about the problems that they are dealing with. Social support
plays a major role in dealing with the disorder in an effective manner. therefore, it
can be said by implementing effective strategies, PTSD among ambulance workers
can be managed effectively. Also, the overall levels of stress and depression is
reduced.
Methodology is an important part of the research and comprises of different
techniques. The methodology of the respective study is explained (Williams and
Williams, 2020). In order to complete the respective study, the researcher has used
secondary data. The researcher has reviewed various articles and journals on the
given research topic. Secondary methods allow the researcher to collect appropriate
and relevant data for the research. There are many advantages of using secondary
methods such as they are easy to access and can be tailored as per the
requirements of the research (Cordova, Riba and Spiegel, 2017). Secondary studies
is frequently used prior to large scale number one research to assist clarify what is to
be learned. For example, a researcher doing competitor evaluation, but who isn't
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familiar with competitors in a marketplace, ought to access secondary sources to
locate a list of capability competitors. Secondary information collection is often used
to assist set the degree for primary research. In the direction of doing so researchers
might also discover that the exact facts they were searching out is to be had through
secondary resources, as a result eliminating the want and rate to wearing out their
own number one studies (Chesmore, Piehler and Gewirtz, 2018). Secondary
research is worthwhile due to the fact it's miles generally more price-effective than
number one research and it offers a basis for any project. Evaluating the modern
panorama of available records before moving directly to number one studies
strategies can keep time and money that may be higher spent elsewhere. As it is
basically primarily based on already existing information derived from preceding
research, secondary research can be conducted quicker and at a lesser price
(Karthik, Saini and Anugraha, 2019). Secondary facts is available from different
assets and may already have been used in preceding research, making it easier to
carry out similarly studies. Secondary information can provide a baseline for primary
research to compare the amassed primary records results to and it can also be
beneficial in studies layout (Williamson and Greenberg, 2019).
By referring to the different journals, the researcher has been able to gather
reliable and accurate information for the study. Secondary methods are useful and
help in including authentic information in the study. The methods are cost effective
and also the process of data collection does not involve a lot of time. Also, by using
secondary methods, the researcher is able to gain new and useful insights about the
research topic. There are a variety of sources available through which the researcher
can gather information. In context to this research, the researcher has tried to
include as many research papers and articles that have reliable information.
Search Strategy
Identical searches were made on three different databases; Medline (1946-2013)
provides medical information on medicine, nursing, dentistry, and health care
system. CINAHL coverage dates back to 1937, mostly relating to Nursing and Allied
Health Literature and Finally PsyoINFO, reviewed literature in behavioural science
and mental health which contained summaries and records dating back to the 1600s.
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Subject headings and key word were conducted using terms relating to: PTSD, Post-
traumatic Stress Disorder, Paramedic, and Pre-hospital. Two searches were carried
out, firstly on the 18th December 2020, later updated on the 28th December 2020
(Gant Chart) the results from the search strategy are below in “Results”.
Results
Medline Database
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CINAHL database
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APA Psycoinfo Database
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PICO Table
P Paramedics, EMS, ambulance staff
I PTSD, Anxiety, Depression, Stress
C Management , Strategies, Intervention
O Reduced sickness, Early Occupational Health, Early Counselling,
Temporary or permanent Redeployment, Downtime.
Search ID Keywords-
Search terms
MEDLINE
Database
CINAHL
Database
APA Psycoinfo
Database
S1 Stress
Disorder
33,491 23,203 0
S2 PTSD 37,131 19,015 42,153
S3 Post-
Traumatic
Stress
34,457 18,429 35,560
S4 Anxiety stress
Depression
53 38 36
S5 S1 and S2 or
S3 or S4
46,038 26,561 46,038
S6 Allied Health
Personnel
11,864 4,323 0
S7 Paramedic 15,978 11,501 1,413
S8 Pre-Hospital 4,925 2,478 285
S9 S6 or S7 or S8 29,904 17,555 1,673
S10 S5 and S9 96 78 48
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Analysis and Discussion
From the above report, it has been analysed that PTSD or Post traumatic
stress disorder is a condition that is most commonly observed in front line workers
such as people working in ambulance services. It is very important to identify and
implement various measures in which the disorder can be handles and prevented
effectively. It is important for all individuals to be mentally healthy because it can help
the individuals to work productively and face the different challenges at their work in
an appropriate manner (Kimura, 2020). Healthcare organizations should consider
implementing job rotation for the ambulance staff because this can help in diverting
their minds and they also get a chance to spend time with their family and friends
(Grubbs and et.al., 2017). There can be several reasons for the poor mental health
of the people working in the ambulance services such as constantly changing shift
patterns, pressure from the management, long working hours and exposure to
trauma. Therefore, in order to manage the disorder in an appropriate manner, the
ambulance workers should be encouraged to speak about their experiences and
appropriate support should also be provided to the ambulance workers. There are
many other ways in which the disorder can be managed in a more efficient manner.
Talking about mental health has become one of the most important topics
because this allows the people dealing with any kind of stress and depression to live
a healthy life. The employers should ensure that the working environment is
supportive and that they are able to ask for help whenever required. Strategies
should be developed to manage Post traumatic stress disorder (Turgoose and
Murphy, 2019). These strategies will not only help in treating the disorder but also
prevent any further signs and symptoms of the same. There can be some
ambulance personnel who are dealing with PTSD and are thus not confident about
speaking about their thoughts with others. It can be said that if PTSD is not managed
in an effective manner, it can lead to further mental health problems such as anxiety
and depression as well as sadness (Kindermann and et.al., 2020). Studies have
shown that among frontline workers, ambulance personnel have reported the highest
amount of tension and troubled thoughts in comparison to other frontline workers
such as military officials as well as firefighters (McKee and Hilton, 2019). There is a
possibility that people dealing with PTSD have been ignored or avoided previously,
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due to which they are not comfortable in speaking up about their thoughts. Due to
this, they might not find it valuable to do so and only continue with their work.
There are different reasons behind poor mental health of individuals such as
long hours of working hours and less supportive working environment. Sometimes
there is pressure from the management about having to performing well. Post-
traumatic stress disorder can be referred to as a mental health condition which
includes the person who has experienced a traumatic incident tends to relive the
same. The symptoms of the respective disorder include nightmares, flashbacks and
avoidance of situations (Murphy and Turgoose, 2020). Among all of the frontline
workers, ambulance workers display the signs and symptoms of the disorder the
most. Posttraumatic stress disorder (PTSD) is a psychiatric sickness that can arise in
human beings who have experienced or witnessed a annoying occasion such as a
herbal catastrophe, a severe accident, a terrorist act, conflict/fight, or rape or who've
been threatened with dying (Lai and Costello, 2021). People with PTSD have
extreme, annoying thoughts and feelings associated with them enjoy that remaining
long after the stressful event has ended. They may additionally relive the occasion
thru flashbacks or nightmares; they will experience unhappiness, worry or anger; and
they'll sense indifferent or estranged from other human beings (Pineles and et.al.,
2018). People with PTSD may additionally keep away from conditions or people that
remind them of the demanding event, and they will have robust negative reactions to
something as regular as a loud noise or an accidental touch.
PTSD falls into four categories based on the level of trauma that the individual
is dealing with. Intrusive thoughts which includes repeated, involuntary
reminiscences; distressing desires; or flashbacks of the stressful occasion.
Flashbacks may be so bright that people feel they may be re-residing the annoying
revel in or seeing it before their eyes (Lee, and et.al., 2020). Avoiding reminders of
the annoying event may additionally encompass heading off people, places,
activities, objects and conditions that could trigger distressing reminiscences. People
may also try to avoid remembering or considering the traumatic event. They may
additionally resist speaking about what befell or how they experience about it
(Schacht and et.al., 2017). Inability to recall important components of the annoying
evet, poor thoughts and emotions main to ongoing and distorted beliefs about
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oneself or others Arousal and reactive signs may also include being irritable and
having angry outbursts; behaving recklessly or in a self-detrimental way; being overly
watchful of one's surroundings in a suspecting way; being easily startled; or having
troubles concentrating or dozing. Effective training should be provided to the
ambulance workers so that they are able to handle their emotions during difficult
situations.
It should be kept in mind that if the situation is not handled appropriately, it
can further impact the overall mental health of the person. They can start losing their
confidence and find it difficult to carry out their job. Proper techniques and processes
to manage the signs and symptoms of PTSD. This is because the nature of their
work is very intense and therefore, it is important to deal with and manage the same
in an effective manner (Song and et.al., 2018). there are also some different ways
that can be adopted for the treatment of people who are dealing with post traumatic
stress disorder. Cognitive Processing Therapy (CPT) is an model of cognitive
remedy that goals closer to the popularity and revaluation of trauma-associated
questioning (Levitan and et.al., 2018). The remedy specializes in the manner
humans view themselves, others, and the world after experiencing a stressful
occasion. Often times erroneous thinking after a worrying event "preserve you stuck"
and for that reason save you recuperation from trauma. In CPT you examine why the
trauma occurred and the effect it has had in your wondering (Song, 2017). Prolonged
Exposure (PE) is every other shape of CBT that is based greater closely on
behavioural therapy strategies to assist individuals step by step method trauma
associated memories, conditions, and feelings. PE specializes in exposures to help
people with PTSD stop fending off trauma reminders. Avoiding those reminders may
also help in the short time period, however in the long term it prevents restoration
from PTSD. Stress Inoculation Training (SIT) is some other form of CBT that aims to
lessen anxiety through teaching coping skills to cope with pressure which could
accompany PTSD. SIT can be used as a standalone treatment or may be used with
some other styles of CBTs. The fundamental goal is to teach human beings to react
differently to react differently to their signs.
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Conclusion
From the above report, it can be concluded that PTSD or post-traumatic
stress syndrome is a serious condition that should be handled and managed in an
effective manner. Not doing so can lead to serious impact on the overall health of the
person. Out of the different people who work on the frontline, paramedics or
ambulance staff members have reported a high level of risk towards developing the
respective disorder. This is because the nature of their work is intense and it is
important to adopt techniques and processes that will help in overcoming the same.
One of the most effective ways that is taken into account when treating the disorder
is to encourage the ambulance personnel to talk. This helps in reducing their stress
and trauma level to a great extent. This is mainly helpful because they get a chance
to discuss about their experience with someone who can provide them with the
required amount of support. Job rotation is another important technique to manage
PTSD among ambulance service workers. In many of the cases, it is possible to treat
post-traumatic stress disorder. Due to this, the ambulance personnel are able to
cope with similar situations further in an effective manner.
PTSD adjustments the body's response to stress. It influences the strain
hormones and chemicals that bring data between the nerves. People who have
suffered childhood abuse or different previous annoying stories are probable to
broaden the ailment, from time-to-time months or years after the trauma. CBT is a
form of psychotherapy that has continuously been discovered to be the simplest
remedy of PTSD both in the short term and the long term. CBT for PTSD is trauma-
targeted, meaning the trauma occasion(s) are the center of the treatment. PTSD
does not continually final forever, even without remedy. Sometimes the effects of
PTSD will go away after a few months. Sometimes they'll final for years – or longer.
Most humans who've PTSD will slowly get better, but many human beings may have
issues that do not leave. Therefore, it can be said that PTSD is a serious condition
and it should be managed by making sure that the personnel is able to carry out their
respective jobs productively.
The causes that can lead to the development of post-traumatic stress disorder
can include serious accidents, experiencing the death of a person etc. The
employers should make sure that the ambulance workers are able to handle extreme
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situations on their own. If not, they should try speaking to them. This is because it
will help them in coping with the situation and also, ask for support in case there is a
need. Effective training should be provided to the ambulance staff workers so that
they develop strong skills. Many studies have been conducted in order to understand
the concept of post-traumatic stress syndrome and find out different ways of dealing
with the same. The results of these studies show that people within the ambulance
service display a greater number of symptoms as compared to other people who
work in the frontline. Therefore, it can be said that it is very important to manage and
treat the disorder to eliminate or avoid any kind of serious impact to the overall
mental health of the person. As a result, the ambulance personnel will be able to
carry out their respective job in an effective manner and also be able to handle any
uncertain situation in the future.
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References
Alharbi, R.J. and et.al, 2020. Current trauma care system in Saudi Arabia: a scoping
literature review. Accident Analysis & Prevention, 144, p.105653.
Ashman, H., Rigg, D. and Moore, F., 2020. The assessment and management of
thermal burn injuries in a UK ambulance service: a clinical audit. British
Paramedic Journal, 5(3), pp.52-58.
Baqai, K., 2020. PTSD in paramedics: history, conceptual issues and psychometric
measures. Journal of Paramedic Practice, 12(12), pp.495-502.
Ben‐Ezra, M. and et.al., 2018. Posttraumatic stress disorder (PTSD) and complex
PTSD (CPTSD) as per ICD‐11 proposals: A population study in Israel.
Depression and anxiety, 35(3), pp.264-274.
Britnell, S.R. and et.al., 2017. Aripiprazole for post-traumatic stress disorder: a
systematic review. Clinical neuropharmacology, 40(6), pp.273-278.
Burruss, G.W., Holt, T.J. and Wall-Parker, A., 2018. The hazards of investigating
internet crimes against children: Digital evidence handlers’ experiences with
vicarious trauma and coping behaviors. American Journal of Criminal
Justice, 43(3), pp.433-447.
Carleton, R.N. And et.al., 2018. Mental disorder symptoms among public safety
personnel in Canada. The Canadian Journal of Psychiatry, 63(1), pp.54-64.
Chatzea, V.E. And et.al., 2018. PTSD, burnout and well-being among rescue
workers: Seeking to understand the impact of the European refugee crisis on
rescuers. Psychiatry research, 262, pp.446-451.
Chesmore, A.A., Piehler, T.F. and Gewirtz, A.H., 2018. PTSD as a moderator of a
parenting intervention for military families. Journal of Family Psychology,
32(1), p.123.
Chirico, F., Nucera, G. and Magnavita, N., 2021. Protecting the mental health of
healthcare workers during the COVID-19 emergency. BJPsych
International, 18(1).
Civilotti, C., Di Fini, G. and Maran, D.A., 2021. Trauma and coping strategies in
police officers: a quantitative-qualitative pilot study. International journal of
environmental research and public health, 18(3), p.982.
Cordova, M.J., Riba, M.B. and Spiegel, D., 2017. Post-traumatic stress disorder and
cancer. The Lancet Psychiatry, 4(4), pp.330-338.
Craig, S. and et.al., 2020. Management of adult cardiac arrest in the COVID‐19 era:
consensus statement from the Australasian College for Emergency
Medicine. Medical Journal of Australia, 213(3), pp.126-133.
Dale, A., 2019. Cover story: Taking on the trauma. LSJ: Law Society of NSW
Journal, (56), p.28.
Dunkley, F., 2018. Psychosocial support for humanitarian aid workers: a roadmap of
trauma and critical incident care. Routledge.
12029145 Word Count Page 27

28
Ebadi, A., Froutan, R. and Malekzadeh, J., 2019. The design and psychometric
evaluation of the emergency medical services resilience scale
(EMSRS). International emergency nursing, 42, pp.12-18.
El-Solh, A.A. and et.al., 2017. The effect of continuous positive airway pressure on
post-traumatic stress disorder symptoms in veterans with post-traumatic
stress disorder and obstructive sleep apnea: a prospective study. Sleep
medicine, 33, pp.145-150.
Elms, L. and et.al., 2019. Cannabidiol in the treatment of post-traumatic stress
disorder: a case series. The Journal of Alternative and Complementary
Medicine, 25(4), pp.392-397.
Forbes, D. and et.al., 2019. Treatment of military-related post-traumatic stress
disorder: challenges, innovations, and the way forward. International Review
of Psychiatry, 31(1), pp.95-110.
Goodyear-Brown, P., 2019. Trauma and play therapy: Helping children heal.
Routledge.
Greinacher, A. and et.al., 2019. Secondary traumatization in first responders: a
systematic review. European journal of psychotraumatology, 10(1),
p.1562840.
Grubbs, K.M. and et.al., 2017. Usual care for rural veterans with posttraumatic stress
disorder. The Journal of Rural Health, 33(3), pp.290-296.
Haagen, J.F. and et.al., 2017. Predicting post‐traumatic stress disorder treatment
response in refugees: Multilevel analysis. British Journal of Clinical
Psychology, 56(1), pp.69-83.
Hichisson, A.D. and Corkery, J.M., 2020. Alcohol/substance use and
occupational/post-traumatic stress in paramedics. Journal of Paramedic
Practice, 12(10), pp.388-396.
Hori, H. and Kim, Y., 2019. Inflammation and post‐traumatic stress disorder.
Psychiatry and clinical neurosciences, 73(4), pp.143-153.
Hruska, B. and Barduhn, M.S., 2021. Dynamic psychosocial risk and protective
factors associated with mental health in Emergency Medical Service (EMS)
personnel. Journal of Affective Disorders, 282, pp.9-17.
Hutchinson, L.C., Forshaw, M.J. and Poole, H., 2020. Health behaviours in
ambulance workers. Journal of paramedic practice, 12(9), pp.367-375.
Karthik, K., Saini, A. and Anugraha, A., 2019. Mortality after Major trauma–An
analysis of the factors that impacts Trauma Survivorship between India and
the United Kingdom. International Journal of Orthopaedics, 6(3), pp.1079-
1084.
Kazour, F. and et.al., 2017. Post-traumatic stress disorder in a sample of Syrian
refugees in Lebanon. Comprehensive Psychiatry, 72, pp.41-47.
Kimura, A., 2020. International technical transfer of training systems and skills in
emergency medicine and trauma management: experiences of the National
Center for Global Health and Medicine, Japan. Global Health &
Medicine, 2(1), pp.24-28.
12029145 Word Count Page 28

29
Kindermann, D. and et.al., 2020. Prevalence and risk factors of secondary traumatic
stress in emergency call-takers and dispatchers–a cross-sectional
study. European Journal of Psychotraumatology, 11(1), p.1799478.
Koek, R.J. and et.al., 2019. Neuromodulatory treatments for post-traumatic stress
disorder (PTSD). Progress in Neuro-Psychopharmacology and Biological
Psychiatry, 92, pp.148-160.
Lai, M. and Costello, S., 2021. Professional Interpreters and Vicarious Trauma: An
Australian Perspective. Qualitative Health Research, 31(1), pp.70-85.
Lee, C. and et.al., 2020. Necessity of trauma referrals to the emergency
department. Proceedings of Singapore Healthcare, 29(3), pp.163-166.
Levitan, M. and et.al., 2018. Paramedics' perspectives on factors impacting on-
scene times for trauma calls. Prehospital and disaster medicine, 33(3),
p.250.
Lewis, C. and et.al., 2020. Psychological therapies for post-traumatic stress disorder
in adults: systematic review and meta-analysis. European journal of
psychotraumatology, 11(1), p.1729633.
McKee, S.A. and Hilton, N.Z., 2019. Co-occurring substance use, PTSD, and IPV
victimization: Implications for female offender services. Trauma, Violence, &
Abuse, 20(3), pp.303-314.
Murphy, D. and et.al., 2017. Post-traumatic growth among the UK veterans following
treatment for post-traumatic stress disorder. BMJ Military Health, 163(2),
pp.140-145.
Murphy, D. and Turgoose, D., 2020. Evaluating an Internet-based video cognitive
processing therapy intervention for veterans with PTSD: A pilot study. Journal
of telemedicine and telecare, 26(9), pp.552-559.
Naushad, V.A. And et.al., 2019. A systematic review of the impact of disaster on the
mental health of medical responders. Prehospital and disaster
medicine, 34(6), pp.632-643.
Orsolini, L. and et.al., 2019. Use of medicinal cannabis and synthetic cannabinoids in
post-traumatic stress disorder (PTSD): a systematic review. Medicina, 55(9),
p.525.
Phelps, A.J. and et.al., 2018. An ambulatory polysomnography study of the post-
traumatic nightmares of post-traumatic stress disorder. Sleep, 41(1),
p.zsx188.
Pineles, S.L. and et.al., 2018. PTSD in women is associated with a block in
conversion of progesterone to the GABAergic neurosteroids allopregnanolone
and pregnanolone measured in plasma. Psychoneuroendocrinology, 93,
pp.133-141.
Regel, S. and Joseph, S., 2017. Post-traumatic stress. Oxford University Press.
Robertson, E.W., 2019. Implementation of a standardized screening protocol to
improve post-traumatic stress disorder surveillance in first
responders. Journal of occupational and environmental medicine, 61(12),
pp.1041-1044.
Roh, S.G., Kim, K.H. and Kim, J.H., 2020. Differences of Emotional Intelligence,
Self-Effectiveness and Job Stress Levels by ambulance worker Personal
Characteristics. Medico Legal Update, 20(1), pp.1578-1584.
12029145 Word Count Page 29

30
Saberian, P. and et.al., 2020. The association between time intervals in emergency
medical services and In-hospital mortality of trauma patients. Archives of
Trauma Research, 9(2), pp.75-80.
Samson, T. and Shvartzman, P., 2018. Secondary traumatization and proneness to
dissociation among palliative care workers: A cross-sectional study. Journal
of pain and symptom management, 56(2), pp.245-251.
Schacht, R.L. and et.al., 2017. Incentivizing attendance to prolonged exposure for
PTSD with opioid use disorder patients: A randomized controlled trial. Journal
of consulting and clinical psychology, 85(7), p.689.
Shalev, A., Liberzon, I. and Marmar, C., 2017. Post-traumatic stress disorder. New
England Journal of Medicine, 376(25), pp.2459-2469.
Sheehan, M., Brent, L. and Deasy, C., 2020. Trauma on Farms in the Republic of
Ireland. Injury, 51(9), pp.2025-2032.
Snowdon, K., 2021. Exploring the clinical debrief: benefits and barriers. Journal of
Paramedic Practice, 13(1), pp.1-7.
Song, D. and et.al., 2018. Role of dopamine D3 receptor in alleviating behavioural
deficits in animal models of post-traumatic stress disorder. Progress in Neuro-
Psychopharmacology and Biological Psychiatry, 84, pp.190-200.
Song, Y.S., 2017. The Relationship Between Fire-fighter's Resilience and PTSD.
Fire Science and engineering, 31(3), pp.119-126.
Storey, K., Kimble, R.M. and Holbert, M.D., 2021. The Management of Burn Pain in
a Pediatric Burns-Specialist Hospital. Pediatric Drugs, 23(1), pp.1-10.
Tehrani, N., 2019. Evaluation of a trauma therapy programme within emergency
service organizations. Occupational medicine, 69(8-9), pp.559-565.
Theleritis, C. and et.al., 2020. Coping and its relation to PTSD in Greek
firefighters. The Journal of nervous and mental disease, 208(3), pp.252-259.
Treleaven, D.A., 2018. Trauma-sensitive mindfulness: Practices for safe and
transformative healing. WW Norton & Company.
Turgoose, D. and Murphy, D., 2019. A systematic review of interventions for
supporting partners of military Veterans with PTSD. Journal of Military,
Veteran and Family Health, 5(2), pp.195-208.
Turgoose, D., Ashwick, R. and Murphy, D., 2018. Systematic review of lessons
learned from delivering tele-therapy to veterans with post-traumatic stress
disorder. Journal of telemedicine and telecare, 24(9), pp.575-585.
Vagni, M. and et.al., 2020. Hardiness and coping strategies as mediators of stress
and secondary trauma in emergency workers during the COVID-19
pandemic. Sustainability, 12(18), p.7561.
Varker, T. and et.al., 2018. Research into Australian emergency services personnel
mental health and wellbeing: an evidence map. Australian & New Zealand
Journal of Psychiatry, 52(2), pp.129-148.
Waltman, S.H., Shearer, D. and Moore, B.A., 2018. Management of post-traumatic
nightmares: A review of pharmacologic and nonpharmacologic treatments
since 2013. Current psychiatry reports, 20(12), pp.1-10.
12029145 Word Count Page 30

31
Wickersham, A. and et.al., 2019. Efficacy of mobile application interventions for the
treatment of post-traumatic stress disorder: A systematic review. Digital
health, 5, p.2055207619842986.
Wild, J. and et.al., 2020. Pre-incident training to build resilience in first responders:
Recommendations on what to and what not to do. Psychiatry, 83(2), pp.128-
142.
Williams, S.D. and Williams, J., 2020. Posttraumatic stress in organizations: Types,
antecedents, and consequences. Business and Society Review, 125(1),
pp.23-40.
Williamson, V. and Greenberg, N., 2019. Post‐traumatic stress disorder: diagnosis
and management. Trends in Urology & Men's Health, 10(4), pp.14-16.
Yatham, S. and et.al., 2018. Depression, anxiety, and post-traumatic stress disorder
among youth in low and middle income countries: a review of prevalence and
treatment interventions. Asian Journal of Psychiatry, 38, pp.78-91.
12029145 Word Count Page 31

32
Dodd, G. (2017) PTSD, Available Support and Development of Services in the UK
Ambulance Service. Journal of paramedic practice Vol 9, No 6.
https://doi-org.brad.idm.oclc.org/10.12968/jpar.2017.9.6.258
Empactis (2020) Absence Manager
file:///C:/Users/basharat.rafiq/Documents/Empactis%20Insights.html (Accessed 17
November 2020)
Felix, T.(2020) American Psychiatric Association. What is Posttraumatic Stress
Disorder ?https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd
Accessed 17 November 2020)
Jonathan et al. (2013) Psychological therapies for chronic post-traumatic stress
disorder (PTSD) in Adults.
https://doi-org.brad.idm.oclc.org/10.1002/14651858.CD003388.pub4(Accessed 18
November 2020)
Mental Health Foundation (2020) Managing Mental Health In The Workplace
https://www.mentalhealth.org.uk/sites/default/files/
CR00233_Ebook_dualbranded_interactive.pdf (Accessed 27.11.20)
Mildenhall, J. (2013) Occupational Stress, paramedic informal coping strategies: a
review of the literature. Journal of paramedic practice Vol 4, No 4
https://doi.org/10.12968/jpar.2012.4.6.318 (Accessed 16 November 2020)
Mildenhall, J. (2019) Protecting the mental health of UK paramedics. Journal of
paramedic practice Vol 11, No.1 https://doi.org/10.12968/jpar.2019.11.1.6 (Accessed
14 November 2020)
Mind (2016). One in four emergency service workers has thought about ending their
lifes.2016
https://www.mind.org.uk/news-campaigns/news/one-in-four-emergency
services-workers-has-thought-about-ending-their-lives/ (Accessed 14 November
2020)
Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting
Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS
Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
http://www.prisma-statement.org/PRISMAStatement/FlowDiagram.aspx
NHS Choices. (2018) Post-traumatic stress disorder (PTSD)
https://www.nhs.uk/conditions/post-traumatic-stress-disorder-ptsd/causes/
(Accessed 16 November 2020)
Appendix 1
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Empactis (2020) Absence Manager (Accessed 10 November 2020)
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