*Katarzyna Zackiewicz1, Maria Dorota Kwika2, Halina Slizewska1, Bogdan Wieczorek3, Jerzy Robert Ladny4
Psychophysical burden of connections with work in the State Emergency Medical Services System in the light of the Public Health strategy
Obciążenia psychofizyczne związane z pracą w Systemie Państwowego Ratownictwa Medycznego w świetle strategii Zdrowia Publicznego
1State Higher Vocational School of prof. Edward F. Szczepanik in Suwalki, Poland
2Institute of Tourism and Recreation, The State School of Higher Education of Szymon Szymonowic in Zamosc, Poland
3Specialist Psychiatric Independent Public Health Care Center in Suwalki, Poland
4Department of Emergency Medicine, Medical University of Bialystok, Poland
Wstęp. Praca zespołów Państwowego Ratownictwa Medycznego (PRM) niesie ze sobą liczne obciążenia czynnikami ryzyka, które w konsekwencji mogą prowadzić do wypadków w pracy, zespołu stresu pourazowego i wypalenia zawodowego. Szereg obciążeń począwszy od zmian w układzie kostno-stawowym, poprzez narażenie na stres, agresję, czynniki chemiczne, fizyczne, biologiczne, łamanie zasad ergonomii wpływa negatywnie na zdrowie ratowników medycznych i absencję w pracy.
Narodowy Program Zdrowia dba o działania profilaktyczne i wdraża odpowiednie zadania, aby zapobiec nieprawidłowościom zawodowym.
Cel pracy. Ocena obciążenia stanu psychicznego i fizycznego ZRM na działanie czynników ryzyka zawodowego oraz ich wpływ na zdrowie i pracę.
Materiał i metody. W prezentowanej pracy magisterskiej zastosowano metodę sondażu diagnostycznego i wykorzystano opracowany kwestionariusz ankiety. Badaniem objęto 34 ratowników medycznych i jedną pielęgniarkę pracujących w Systemie Państwowego Ratownictwa Medycznego w Suwałkach, Olecku i w Augustowie od września do grudnia do 2016 roku.
Wynik. Pracownicy Systemu Państwowego Ratownictwa Medycznego są narażeni na szereg obciążeń, urazów i dysfunkcji związanych z wykonywaną pracą. Narodowy Program Zdrowia ma za zadanie niwelować tego typu niedogodności poprzez różne zadania profilaktyczne i prewencyjne. Okazuje się, że przy takiej specyfice pracy nierealne jest w pełni przestrzeganie dobrych praktyk stosowanych na stanowisku pracy.
Wnioski. System Państwowego Ratownictwa medycznego, a w szczególności członkowie ZRM, idealnie wpisują się w zadania NPZ, jednak jedynie jako negatywny przykład braku realizacji strategii Zdrowia Publicznego.
Introduction. The work of the State Medical Rescue (PRM) team carries with it numerous risk factors, which in consequence may lead to accidents at work, post-traumatic stress disorder and burnout. A number of loads ranging from changes in the bone and joint system, through exposure to stress, aggression, chemical, physical and biological factors, violation of the principles of ergonomics adversely affect the health of paramedics and absenteeism at work.
The National Health Program takes care of preventive actions and implements appropriate tasks to prevent occupational irregularities.
Aim. Assessment of the psychological and physical burden of ZRM on the risk factors and their impact on health and work.
Material and methods. In the presented thesis the method of the diagnostic survey was used the questionnaire. The study included 34 paramedics and one nurse working in the State Medical Rescue System in Suwałki, Olecko and Augustów from September to December of 2016.
Results. Employees of the State Medical Rescue System are exposed to a number of burdens, injuries and dysfunctions related to the work performed. The National Health Program is in favor of eliminating this type of inconvenience through various preventive tasks. It turns out that with such specificity of work it is not realistic to fully observe the good practices used at the workplace.
Conclusions. The system of State Emergency Medical Services, and in particular, the members of ZRM fit perfectly into the tasks of the NPZ, but only as a negative example of the failure to implement the Public Health strategy.
„Public Health as a science and art of disease prevention, prolonging life and promoting physical health through organized effort of the society, supervision of environmental hygiene, prevention of infections” (1). The definition of Public Health defines the scope of activities carried out under the health strategy in the area of social activities. The basic document of public health policy in Poland is the National Health Program (NPZ) is a document compliant with the Public Health Act and established by the regulation of the Council of Ministers. This document is issued for at least 5 years and contains the basic strategic, operational and key objectives that should be implemented to improve the health and quality of life of the society. The NPZ’s strategic goal is to reduce inequities in the health of people with different social statues, extend the lives of Poles and improve the quality of life associated with health. The National Health Program combines many preventive programs and is an integral part of social and health policy. In the currently binding National Health Program for 2016-2020, we distinguish six main goals. One of them, which fits into the subject matter, talks about the need to reduce the health risk associated with biological, physical and chemical hazards in the external environment, as well as the workplace, study and residence. As part of this objective, initiatives are taken to prevent occupational and work-related diseases. The most important aspects of this goal are the introduction of procedures for early identification of hazards related to the work environment, raising awareness of the need to maintain a hygienic lifestyle, including the introduction of preventive measures. So how does work in the State Medical Rescue System (PRM) work in the strategy of public health and preventive activities?
PRM system employees, like victims of accidents, traumatic events or catastrophes, are exposed to strong stress. A factor contributing in a special way to the increase of tensions related to work in PRM is the very nature of events described as traumatic. In order to be able to work in the State Emergency Medical Services, a number of formal requirements defined by the legislator should be met, as well as qualifications, physical and psychological abilities. Due to the specificity of working in the PRM System, it is difficult to clearly determine the place of work of Medical Emergency Teams (EMT). It depends on the type, place and nature of the event called by the legislator as the area of activity. The locations of ZRM and their number are determined by the Provincial Member of the State Emergency Medical Services System for individual provinces.
The risks associated with working in the PRM system relate to psychosocial, physical, biological, psychological, chemical and ergonomic factors. This wide range of risk factors results from the specifics of work.
Psychosocial factors play an increasingly important role in the work of travel teams. These include high demands at work, traumatic experiences, or aggression and violence applied to employees of the PRM system. A victim who is in a state of threat to life and health experiences stress and fear related to his or her loved ones’ situation. Some of them are respond in such circumstances passively, showing depressive tendencies or withdrawal. Others react with aggression. It turned out that among those victims showing negative behavior at the time of injury, up to 40% is under the influence of alcohol and/or psychoactive substances (2, 3). The paramedic/nurse and the physician of the system during the performance of medical rescue operations use the rights of a public officer, and therefore they can exercise their rights to protection in court. An important aspect in this situation are actions taken by the justice system, which can be a kind of “bogey” for potential aggressors who could commit aggression against PRM system employees. Another factor that can negatively affect the mental and physical condition of employees of the PRM system is the shift work system. Disorders in the functioning of the “biological clock” can adversely affect memory processes and concentration. This situation may contribute to unintentional accidents at work (4). The negative effects of this type of work can be divided into three basic types: 1) sociological factors that depend on gender, age, marital status or personality traits; 2) health factors that in an abnormal way may affect the course of human work; 3) biological factors. Night work negatively affects interpersonal relationships: family, social and intimate.
The changeable mode of work predisposes to improper functioning of the circulatory, digestive, hormonal, sleep and procreation systems. Such functioning at work increases the risk of addiction.
Accidents and random events
PRM employees, bypassing their own safety rules, risk their health to save others. They forget about the fundamental principle: “personal safety”.
Central Institute for Labor Protection by analyzing accidents at work, which are subject to medics. Replacing situations (impacts on stationary objects, mainly in ambulance equipment, objects in the area of operation), which can cause injuries, such as: fractures, bruises, cuts, trapping, wounds in contact with sharp objects. In addition, inadequate lighting can reduce the visibility of various obstacles and lead to personal injury. Slippery surfaces in turn cause the lifeguard’s slips and falls in the area of operation. However, traffic accidents on the way to the place of the accident or during the return of the ambulance can lead to numerous injuries or even death. Falls from heights occurring during the flight of rescuers from the stairs (during transport of the patient), may result in injuries, mainly head and spine. On the basis of accidents registered by the Ambulance Service in Wrocław in 2005-2010 a list of accidents at work was created, which is shown in figure 1. Exposure to infectious material, as well as accidents related to it are included in the occupational risk of paramedics. In unfavorable working conditions of ZRM, it is not difficult to puncture contaminated needle, which is also considered as an accident at work. Working environment, rush, restless patients, often aroused, can cause the needle to slip and stab (5).
|Type of event||Years||Total evens|
|Cutting with a sharp object||1||1||1||1||0||0||4|
|Hitting a stationary element||2||2||4||3||3||0||14|
|Blow on a movable element||7||0||4||3||4||6||24|
|Fall at the same level||1||0||4||4||4||9||22|
|Fall from the stairs||0||5||1||5||4||6||21|
|A blow when getting out of the ambulance||1||5||3||1||7||4||21|
|Trauma during manual transport||3||10||8||13||21||17||72|
|Stabbing with a dirty needle||4||4||6||15||14||6||49|
Fig. 1. The accidents at work of employees of the Ambulance Service in Wroclaw in 2005-2010
In the first place among the professional population threatened with the negative effects of harmful biological factors are health care workers (6). Work in health care, including the State Medical Rescue System consists in providing medical assistance to patients, regardless of their state of health or hygiene, which is why the patient’s infected, infected the environment, infected medical equipment, infected medical supplies should be considered including dressing as a source of risk for biological agents.
Harmful biological agents can have an allergic, toxic effect, lead to an infectious disease. Microbes occurring in health care facilities are characterized by higher than normal virulence and pathogenicity. The blood-borne pathway of transmission of microorganisms is associated with the possibility of infecting with dangerous pathogens.
One of the most dangerous pathogens with which medical rescuers can meet in their professional practice are viruses that cause hepatitis (HBV, HCV), HIV, staphylococcus aureus, tuberculosis mycobacteria, tetanus bacillus, influenza viruses, herpes virus, HPV, ebola virus (7). Diseases caused by the most dangerous of pathogens are rare, but the risk of getting sick is higher than in the average healthy person. The most frequent infections occur as a result of an accidental needle-pricked needle, contact with damaged skin, mucous membrane and body fluids. Therefore, personal protective equipment is an important element of prevention against infection.
Chemical factors that PRM employees have contact with during their professional work include latex, disinfectants and sterilants, medicines and other chemicals. These and other substances, depending on the type and concentration may cause allergic reactions, lead to irritation of the mucous membranes of the airways, to skin changes or severe anaphylactic reactions. Contact with chemical agents that may have irritating or sensitizing properties, entails a risk of getting ill.
Sensitization to latex is quite common, which is why nitrile gloves have been introduced to prevent the occurrence of allergic reactions. In terms of safety, nitrile gloves show better protection (8).
Some sources indicate exposures to chemical agents and related complications, as highly harmful and even carcinogenic. Changes in the genetic material caused by long-term exposure to a chemical agent can cause damage and lead to mutations.
Analyzing the work process of medical rescuers or nurses, it can be unequivocally stated that there are many factors that increase physical loads, one of them is the way of performing work and organizational working conditions. Forced body position, lifting and transfer of oversized weights, the size of the unit load of employees has a negative impact on their physical condition.
A diverse work environment of paramedics, exposes them to physical factors from excessive exposure to heat and cold, mechanical vibrations, and electric shock or fire. In addition to the negative impact on health, exposure to certain factors can lead to serious injuries and significant damage to health, can be a cause of considerable discomfort or the cause of the disease.
Noise is one of the physical factor considered to be onerous, occurring in the work of physicians. Harmfulness of noise depends on the frequency of vibrations, intensity and time of exposure. Mechanical vibrations that accompany your work every day while transporting a patient may have a negative effect on the bone-joint and muscle system. Lighting using natural and artificial light enables safe work, however, due to the specificity and diversity of circumstances prevailing during medical rescue operations, this condition is often not met. The negative effects of the lack of proper lighting at work include sudden injuries, accidents, errors in the performance of activities, or diseases of the eye.
Work ergonomics is one of the most important elements affecting health in the work environment. The specificity of the work of a paramedic is far from the correct patterns of ergonomics in the workplace. The most “strained” is the osteoarticular system, especially the spine. To a large extent people who are in a state of immediate threat to life or health are not able to move independently, so they must be transported manually to the ambulance. Carrying patients and their transmission negatively affects the state of health, leads to numerous micro-injuries in the muscles, muscle fascias and joints. Forced, unnatural body position can increase the risk of musculoskeletal system loads. The numerical value of the weight that can be lifted by a woman according to ergonomic standards should not exceed 25 kg, and for men – 30 kg. However, in the current legal situation, which allows the functioning of two-person ZRM, this condition is not met and therefore there is widespread violation of work safety rules. In addition, the number of trips is constantly increasing, which also increases the number of patients in need of manual transport. This obligation rests on the members of EMT who need to stabilize and then transport the patient in a life-threatening condition.
The Central Institute for Labor Protection in 2013 conducted research on threats to the work of paramedics. Based on the research, he concluded that the biggest health problem in the work of paramedics is back pain, mainly the lumbar section, followed by the cervical and thoracic segments. In contrast, lower extremity pains are a much less common phenomenon, as are upper limbs (9).
An important problem in the work of paramedics is the ergonomics of work. The standards regarding the technical requirements of emergency vehicles, as well as the scope of necessary equipment are regulated by the legal letter in the form of the Ordinance of the Minister of Infrastructure of December 31, 2002. Dz. U. of 2003 No. 32, item 262.
In addition, the provisions in force in the Polish Standard PN-EN 1789 for a means of transport cat. B oblige to maintain standards for ambulances.
Stress and burnout syndrome
Employees of the PRM system are exposed to stressful situations alternating with periods of peace and routine. This determines additional work-related tensions. Excessive duties, traumatic nature of events, incorrect interpersonal relationships, increase the negative work experience. Feeling helpless when dealing with inevitable death affects destructively the psyche, causing it to “exhaust”. Long-lasting stressful action reduces the body’s resistance and consequently leads to disease (10, 11).
Work in emergency services requires special personality predispositions and mental resilience. Usually contact with the victim is short-lived, but the feelings accompanying the meeting, especially in traumatic situations, are permanent. Trust is essential to establishing a good relationship with the patient. The problem arises at the moment when the employees of the system are left with the decision not to take or stop medical rescue operations (MDGs). This applies to patients with massive injuries or in cases that do not survive. Being with a dying person and contact with his family is highly stressful.
The burnout syndrome that occurs among employees of the PRM system is an example of the fact that their work is responsible and trembling. The reasons for professional burnout include: the nature of the work, its nuisance, the degree of commitment to responsibility incurred during its performance, high requirements, working conditions, the number of stressful or considered to be cumbersome situations, interpersonal contacts, high work pace.
Medics are also exposed to post-traumatic stress disorder and are characterized by intrusive, recurring memories. The reason for his appearance may be contact with upcoming death, traumatic situations. It also happens that people affected by PTSD identify with the victim, which intensifies the sense of anger.
PTSD (post traumatic stress disorder) is characterized by a symptom of conversion (intrusion) – experiencing a negative event anew, in the form of bad memories and dreams, moreover symptoms of avoidance, ie, escape from stimuli, conversations related to a traumatic event. PTSD may also be manifested by psychophysical stimulation, which is manifested by violent outbursts of anger, difficulties with concentration of backfilling, shallow sleep and awakenings (4). However, positive changes after bad experiences, being a kind of motivator, are often observed. This phenomenon is called posttraumatic growth, or posttraumatic self-development, which means positive changes in self-perception and attempts to cope with experienced stress (4).
The aim of the work is to assess the psychological and physical burden of EMT on the risk factors and their impact on health and work.
MATERIAL AND METHODS
Own research: The study included 34 paramedics and one nurse working in the State Medical Rescue System in Suwałki, Olecko and Augustów from September to December 2016.
The majority of respondents are men (28 men, 80.0%), and the remaining (7 women, 20.0%) are women. In the presented thesis the method of the diagnostic survey was used and the questionnaire was developed for this purpose. The questionnaire contains 31 questions about psychophysical loads, work accidents, stressful situations, burnout syndrome, traumatic events and their impact on the mental and physical state of the respondents.
When asked about the number of years worked in the PRM system – the largest group (14 people, 40%) is made up of respondents who work between 5 and 10 years in the profession, followed immediately by people whose work experience is above 20 years (10 people, 29%). Then 5 people (14%) work in the 11-15 age group, and only 4 (11%) – under 5 years. The smallest group are medics who have worked for 16 to 20 years (2 people, 6%). More information on this topic is shown in figure 2.
Fig. 2. The years spent in the State Medical Rescue System
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