In the field of emergency services, being exposed to a high level of physical and psychological stress is a serious health risk factor for frontline workers. While the last few decades have seen an increase in awareness around the mental health issues that impact firefighters, police, and soldiers, the support of ambulance workers has received less attention in the healthcare sector. However, studies have shown a growing rate of mental health problems, burnout, drug use, and chronic illnesses among ambulance and emergency healthcare workers.
Ambulance workers face crises, natural disasters, and human tragedies as part of their everyday jobs. Emergency situations are usually out of human control, unpredictable, and physically and psychologically dangerous. Ambulance workers are under constant pressure to make the right decisions to save lives, often while racing against time.
In this article we introduce the Hungarian mental healthcare practice for ambulance providers. After reviewing the main characteristics of the Hungarian National Ambulance Service (NAS), we will look at relevant psychological theories and methods that can be used in providing psychological support for ambulance crews. Finally we will unfold the short history of our professional group, including the main psychological interventions we use to support Hungarian ambulance workers’ healthcare.
The NAS in Hungary was founded more than 70 years ago. Its center in Budapest is complemented by regional centers that operate a network of ambulance stations throughout the country. The number of employees working in these stations varies depending on the population of the region.
Frontline workers make up the largest number of staff within the organization. ALS- and BLS-level units also partake in rescue missions. These groups consist of paramedics, specialist or emergency doctors, and other ambulance crew. The centralized (national and county-level) dispatcher services supplement the frontline work by receiving emergency calls and alerting the different levels of units. The work of the frontline ambulance and dispatcher services is supported by the so-called “back office,” which oversees the administrative and human resources sides of the work.
There was no mental health or psychological support of ambulance workers in Hungary until the beginning of the 2000s, despite clear signs support around this area would be necessary. The first official step toward achieving this was made in 2011 by a psychiatrist who was also a first responder. One of the first arrangements put in place was to start a 24-hour crisis line especially designed for ambulance workers.
In 2013, thanks to a project introduced by the European Union, a burnout team was set up in Budapest. The team consisted of a psychiatrist, two psychologists, and a paramedic officer. The goal of this group was to emphasize the importance and promote the mental health and well-being of ambulance workers, as well as to identify and support those affected with psychological problems, especially the symptoms of burnout. In the next few years, the group—with continual support from leadership due to its ability to meet the workers’ needs—gradually expanded with new additions to the team, including colleagues working in the country’s regional centers. By 2019 the NAS’ Psychological and Mental Health Group had grown into a network of psychiatrists, psychologists, and mental health workers who consider the support of ambulance workers’ mental health the first and foremost function of their profession. Each professional member is responsible for work within an assigned region of the country.
To supply an adequate mental health care system, it was important to explore the needs of the employees and main characteristics of their everyday work.
At first we carried out worker surveys to determine the current psychological state of the ambulance staff, which we then used to identify the best mental healthcare interventions. Our studies involved both frontline workers and dispatchers. We attempted to reveal the impact high-intensity stress, crisis situations, and the workplace environment can have on ambulance workers and determine their risk of developing burnout symptoms as a result. Recognizing that low-intensity stress can similarly lead to long-term effects on mental health, the study also looked at the impact of workplace conflicts, excessive leadership expectations, and bullying.
It has become an important task to promote and preserve the psychological well-being of our employees, prevent burnout syndrome, and reduce the level of employee fluctuation. To achieve this we needed a wider theoretical framework, one that accounted for aspects of social, organizational, crisis, and personality psychology, while also reflecting principles of trauma recovery. The specifics of the frontline workers’ personalities, their coping mechanisms, the peculiarities of emergency situations, and doctor-patient relationships were all considered essential aspects for building an effective psychological care system.
Due to the lack of psychological interventions for ambulance workers in the past, we had to create our own operational and therapeutic principles. These now form the basis of a comprehensive psychological approach we use to provide support for every staff member working for the NAS.
Therapy—One of the most important aspects of our job is to provide therapeutic support. As our team includes psychologists, psychiatrists, and mental hygiene professionals, we are able to provide expert support to those who need it. We first offer supportive consultations for the ambulance workers and, depending on the capacity of the team, individual psychotherapy as well. The service is provided using a self-referral system.
Crisis intervention—Deaths, multiple-casualty accidents, violent assaults, and the deaths or suicides of colleagues are the main high-risk emergency events that can cause acute or post-traumatic stress symptoms. Our aim is to provide individual and group crisis interventions to help the ambulance staff cope better and prevent the development of long-term consequences from such events. Working in cooperation with the dispatcher services, we are able to follow up on these happenings throughout the country on a daily basis. Following a high-risk event, we immediately start to organize psychological support for ambulance workers who are directly affected. The purpose of the debriefing process (our group crisis intervention) is for ambulance workers to be able to share all their feelings, thoughts, and symptoms related to the event and enhance the social support between ambulance workers.
Education and training—Besides the therapeutic interventions, we support frontline and dispatch work by teaching different psychological and communication tools and developing professional and personal skills essential to control extreme and stressful situations. The main topics of our presentations include crisis communication, suggestive communication, panic control treatment, and the psychological aspects of multiple-casualty accidents.
Furthermore, we offer short training programs focusing on the topics of assertive communication, conflict management, and stress management. Relaxation technics—e.g., autogenic training or mindfulness—can develop concentration and emotional control and also increase performance.
To maintain a stable and professional identity, it is crucial to be aware of our own resources that can serve as a protective factor in emergency situations. We therefore also use our trainings to emphasize the importance of self-awareness and the adaptive ways of recreation.
Team supervision—Working directly with psychological disturbance can be overwhelming for psychologists as well sometimes; thus our own supervision is vital. As we work far from each other, we have to find different ways to support each other and strengthen the cohesion of our team.
Team supervision can provide different perspectives for therapeutic or crisis cases, and this process guarantees our own professional development. By learning from these experiences, we become better prepared for challenges yet to come and can enrich the theory and practice of the field of emergency psychology.
Research—One of our main priorities is to regularly monitor the mental and psychological state of the ambulance staff. Our research studies have measured the specific personality factors (e.g., coping strategies) and different mental health problems (e.g., burnout syndrome, PTSD) of both first responders and dispatchers. In addition we attempted to survey the conditions of the frontline work, such as cultural differences in emergency healthcare.
We plan to repeat our surveys in the future and compare the findings with our previous results. With this we will be able to monitor the current mental health state of our ambulance workers and follow up on burnout syndromes and other problems. Our results open up new pathways in the mental healthcare of ambulance workers in Hungary.
In the coming years we would like to continue our work in the field of psychological therapies, crisis interventions, education, and research. We will continue promoting the importance of supporting the mental health of ambulance crews by representing our team at various events and forums.
Furthermore, we would like to give more attention to our own education and personal and professional development. Accordingly, we have plans to approach the Hungarian Balint Society for Psychosomatics to study and adapt its methods. This technique focuses on the “helper-client” relationship—especially in overwhelming and conflict situations or repeated situations the helper cannot manage effectively. In the Balint group the participants’ communication, professional, and personal competencies develop, and their self-knowledge deepens.
In 2019 burnout was declared an occupational phenomenon by the WHO. As burnout is a considerable problem among ambulance workers in Hungary, we intend to create a complex burnout-prevention program that addresses the different levels of the organization. A prevention program has to be based on the current organizational culture and take the characteristics of individual careers into consideration (e.g., entrants vs. pensioners).
On the individual’s side it is important to improve the conscious use of “psychological armor” and facilitate post-traumatic growth. Positive psychology offers a great theoretical background by focusing on the individual and group strengths and possibility of personal development. Our trainings and lectures can increase the frontline workers’ confidence that helps them combat everyday stressors.
It is worth noting that sometimes the helpers need help. Hopefully our appearance in the international field will open new directions for our work. We are highly interested in creating a connection with similar teams around the world.
The authors are members of the Psychological and Mental Health Group of the Hungarian NAS. Contact firstname.lastname@example.org. The authors gratefully acknowledge the director general of NAS, Dr. Gábor Csató, and its medical director, Dr. György Pápai, for their support of this article.
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Research of the Psychological and Mental Health Group of NAS, Hungary, in press.