Systematic reviews of the literature on the health and work environment of ambulance personnel have over the last decade emphasised what appears to be an increased risk of developing work-related health problems among this particular occupational group [1
]. Earlier studies have shown that ambulance personnel have a ten-fold higher rate of early retirement than nurses, and a doubled risk compared to those carrying out manual work in the health sector. The leading causes of early retirement are musculoskeletal disorders (MSD), diseases of the circulatory system and mental illness [4
]. Of special interest has been the observation that emergency service work is inherently stressful. Ambulance personnel need to provide medical assistance in critical and unknown situations where those in need of help are at risk of dying if care is not given swiftly and appropriately. In addition, ambulance personnel will often face situations in which relatives afraid of losing their loved ones or other bystanders will be watching them while they carry out their work. All of this contributes to the inherently stressful nature of their job [6
Because of the stressful nature of emergency service work, most studies of ambulance personnel have addressed psychological health outcomes [7
]. Posttraumatic stress disorder (PTSD) symptoms have been reported with prevalences of 15–20% among ambulance personnel, which is 4 to 10 times higher than in the general population and far above what is seen in other occupational groups exposed to sudden serious psychological hazards [7
]. Furthermore, other psychological outcomes such as burnout, depression and anxiety have been the topic of a few studies, where an elevated prevalence of symptoms has been reported [9
]. Unfortunately, most studies lack the data quality or normative data that would enable comparisons across different occupations. Thus, overall there is a lack of conclusive evidence about the prevalence of mental illness and other psychological outcomes among ambulance personnel compared to other occupations on the labour market (1). The same is seen in studies of the somatic health of ambulance personnel, where even fewer studies were identified in recent reviews of the literature [1
]. MSDs have only been investigated in regard to well-known hazards such as heavy lifting, bending and carrying [14
]. However, other physical exposures are probably also relevant because of the unpredictable nature of emergency service work. Exposures such as working in awkward postures with sudden and unexpected movements or having to perform maximum force exertions should be investigated as well. Working with in-transit care in the rescue vehicle, which requires reaching for overhead equipment and horizontal bending and twisting, has been identified as the most risky exposure for developing musculoskeletal pain in an American study based on observations of training exercises [16
]. All in all, this also points to a lack of research into important aspects of the physical work environment of ambulance personnel.
Ambulance services in Denmark
In Denmark, five regional counties have the responsibility for hospital and pre-hospital service. Contrary to several other countries, no hospitals in Denmark have their own integrated ambulance departments. Since 1963, there has only been one major ambulance service provider in Denmark. This private provider has covered most of the country apart from areas within four counties where the fire department also runs the ambulance service (covering Copenhagen, the Danish capital, and some counties in the vicinity in which another private contractor has won the tender). Besides ambulance service, the company also performs the majority of other emergency services in Denmark, including fire fighting, animal rescue, patient transportation, roadside assistance, environmental assistance, and various forms of health care education and assistance to private people and public institutions. In 2008, Denmark’s five county governments have started putting ambulance service out to tender every fourth year. The first tender changed little in the overall structure of the Danish ambulance service, with one new private ambulance provider taking over some of the districts that had formerly been run by the original company. Despite this, the biggest ambulance provider still covers 85% of all emergency operations in Denmark. All in all, approximately 4500 persons are employed as ambulance personnel in Denmark. Each county assembles the pre-hospital service individually and puts the service to tender. The set-up and the running of the pre-hospital service differ slightly between the five Danish counties. Some counties have, for example, chosen a model with a specific permanent emergency standby, defining the numbers of ambulances, personnel, ambulance stations, etc. In other counties, there is no minimum permanent emergency standby. The ambulance service provider instead has the responsibility for ensuring specific maximum response times, but has considerable autonomy to set up the emergency standby as it finds it most appropriate to ensure the contractually required response times.
Until the middle of the 1990s, Danish ambulance workers received little formal education. However, as the ambulances became increasingly equipped, and especially with the introduction of the defibrillator, a formal emergency worker/ambulance assistant (level 1) vocational education was introduced. Subsequently, an additional 5
week treatment provider (level 2) education was introduced, and in 2004, a formal 11
week paramedic (level 3) education was introduced. Hence, unlike many countries, Danish ambulances are not staffed by nurses. Danish legislation requires that ambulances must be staffed with at least two persons. At least one of these must be an educated treatment provider and the other must have passed an exam as an assistant provider. Most of the ambulance personnel perform more than one job function, e.g., rotating between emergency ambulance driving and transportation of patients over the work week. However, procurement rules require that companies that compete for tender must keep their sectional services separate in the daily operation. This has introduced a more rigid handling of jobs that could affect the work environment. The former board portfolio of jobs gave the local station-manager more flexibility to spare ambulance-workers by assigning them to less demanding tasks such as patient transportation for smaller or longer periods of time.
Aims and scopes of the paper
The aim of this paper is threefold: 1) to compare various aspects of health status among Danish ambulance personnel with that of the general work force in order to establish whether prior findings of more musculoskeletal pain and more mental health problems in this occupation can be replicated; 2) to describe the general work environment among ambulance personnel and compare the psychosocial work environment to other occupations; and 3) to examine the associations between the physical and psychosocial work environments and five health outcomes.