R. Nicholas Carleton and Gregory S Anderson analyse the workplace stressors and risks of public safety personnel and front-line healthcare workers
Using an interdisciplinary team approach, doctors Anderson and Carleton have a long history of exploring the impact of potentially psychologically traumatic events (PPTEs; i.e., direct or indirect exposure to actual or threatened death, serious injury, or sexual violence) and other workplace stressors on the mental health and wellbeing of essential workers.
Anderson and Carleton are part of a national network of academics, researchers, and clinicians, coordinated with the Canadian Institute for Public Safety Research and Treatment (CIPSRT). The network has focused on workers at increased risk – including first responders and other public safety personnel (PSP), and front-line health care workers (FHCW).
Public safety personnel include but are not limited to: border services personnel, correctional workers, firefighters, paramedics, police officers, and search and rescue personnel.
Front-line healthcare workers include but are not limited to: nurses, physicians, and staff in an emergency, trauma, psychiatric, or other intensive care units.
Essential workers experience thousands of traumatic events
Fight, flight or freeze are all response options for PPTE exposures and some other intense stressors. Most civilians have limited exposure to substantial stressors (i.e., typically fewer than five and in some cases none); in contrast, PSP and FHCW, who are essential workers in most societies, necessarily experience thousands of PPTEs as a function of having dedicated their working lives to protecting, serving, and saving others.
Our PSP and FHCW work in their own communities, where they live with their own families and friends; accordingly, their sense of duty means that collectively and individually, they are effectively serving or on-call 24 hours a day, 365 days a year.
As essential workers, PSP and FHCW serve even under the most severe conditions (e.g., the height of the COVID-19 pandemic), often with little or no recourse or relief. Contemporary research results have underscored the depth and breadth of increased mental health risks for PSP and FHCW, who appear at significantly and substantially increased risk for several operational and posttraumatic stress injuries (PTSI), including but not limited to symptoms of major depressive disorder, panic disorder, generalized anxiety disorder, posttraumatic stress disorder, substance use, and suicidal ideation, planning and attempts.
How do Canadian essential workers compare in well-being?
A recent pre-pandemic pan-Canadian study of PSP evidenced 44% reported symptoms consistent with at least one mental health disorder – much higher than the diagnostic prevalence of 10% for the general Canadian population, which would have included PSP. PSP also appeared to have much more difficulty with lifetime suicidal ideation, planning, and attempts, with as many as 1 in 10 reporting having tried to die at least once – much higher than the 3 in 100 attempts for the general Canadian population, which would have included attempts by PSP.
A similar study with the Canadian Federation of Nurses Unions evidenced that 48% of nurses reported symptoms consistent with at least one mental health disorder and nearly 1 in 10 reported having tried to die at least once. The nursing research also evidenced that nearly 1 in 3 nurses were experiencing clinically significant levels of burnout. The pre-COVID-19 pandemic results were alarming, and we have every reason to believe the situation for PSP and FHCW has since become much worse.
Operational and organizational stressors for PSP and FHCW
PSP and FHCW are frequently and repeatedly exposed to PPTE as an inherent operational stressor, exposures that appear related to PTSI; however, pre-pandemic research evidenced that PSP and FHCW are also frequently and repeatedly exposed to a myriad of other operational and organizational stressors that can also have substantial negative impacts on their mental and physical health, stressors that may have larger impacts than PPTE exposures.
PSP reported difficulties with numerous stressors, including but not limited to staff shortages, inconsistent leadership styles, shift work, inadequate equipment, and public scrutiny. Similarly, FHCW reported difficulties with staff shortages, unpredictable scheduling, unsupportive leadership, and inadequate equipment, as well as workplace abuse, harassment, and assault. There are numerous challenges with reducing PPTE exposures for essential workers.
PSP and FHCW receive extensive training and have access to direct support, but the effectiveness of such activities for offsetting PTSI remains relatively unknown. In direct contrast, there are numerous opportunities to reduce other operational and organizational stressors for PSP and FHCW (e.g., increased staffing), most of which can reasonably be expected to help improve their mental health, increase retention, and by extension, further support our communities.
How do these traumatic events impact occupational performance?
Intense and chronic stressors and subsequent PTSI or other mental health challenges can negatively impact the quality of occupational performance, increase absenteeism, increase sleep difficulties, negatively impact interpersonal relationships, increase burnout, and increase early mortality.
There are poignant moral arguments supporting a duty to support essential workers who take on such increased risks for their community. In addition, estimates of productivity losses from mental disorders suggest an annual cost to Canadians of approximately $20 billion. The costs have prompted several stakeholder organizations and occupational health policymakers to seek proactive approaches, such as implementing mental health training programs to mitigate the impact of operational and organizational stressors on workers, along with efforts to improve access to evidence-based treatment programs. Proactive efforts to support mental health may be particularly relevant for PSP and FHCW, given evidence that mental health stigma substantially inhibits their seeking care.
Analysing the effectiveness of services and programs without conflicts of interest
Despite the important contemporary efforts and a plethora of solutions proffered in the marketplace, there are substantial gaps in research and peer-reviewed literature regarding the effectiveness of organizational efforts to mitigate or remediate PTSI among PSP and FHCW. The available evidence suggests small and time-limited benefits, is generally of moderate-to-low quality, mostly cross-sectional, with diverse outcome measures and follow-up durations, and almost no standardization.
As policymakers move forward with legislating better access to mental health services and programs for all at-risk workers, formal evaluations of the effectiveness of services and programs by researchers without inherent conflicts of interest will be crucial for making meaningful improvements for individuals and communities. The absence of such evaluations will represent failures to properly protect those who serve and risks low returns on taxpayer investments.
