Exploring the psychological health of emergency dispatch centre operatives: a systematic review and narrative synthesis

Introduction

Working in a healthcare environment can be stressful; healthcare staff face a range of situational, organisational and interpersonal stressors in their roles and a significant proportion of staff report feelings of emotional exhaustion and burnout (Tuvesson, Eklund & Wann-Hansson, 2011; Gokcen et al., 2013; Andersson et al., 2016; Qiao et al., 2016). Additionally, staff in emergency settings are regularly exposed to demanding and traumatic situations, including severe injuries, aggressive individuals, and death (Lin et al., 2007; Adriaenssens, De Gucht & Maes, 2015). Emergency medical work can be unpredictable and can be physically, cognitively and emotionally demanding. Ambulance personnel have to make rapid assessments of patients and situations, and these assessments carry both professional and social responsibility. Working in stressful conditions, with repeated exposure to challenging situations, can impact negatively on both the physical and psychological health of ambulance personnel, and may lead to burnout amongst some individuals (Halpern et al., 2012; Sofianopoulos, Williams & Archer, 2012; Fjeldheim et al., 2014).

Before ambulance personnel attend a scene, the incident is first reported to an Emergency Dispatch Centre (EDC) for processing. EDC operatives do not provide any hands-on first aid; instead, they triage the incident, which involves management of a unique set of challenges. They cannot see what is occurring at the scene and are reliant upon the caller’s descriptions, which may be ambiguous, to infer the patient’s needs. EDC operatives must interrogate the caller, who may be distressed, to collect as much information as possible and assess the call’s urgency. The operative then relays relevant information about the patient’s condition and location to an ambulance crew, and if necessary, the operative remains on the line to provide immediate life-saving advice.

Although they are removed from the scene of the incident, EDC operatives work in an environment characterised by some of the same difficulties encountered by front-line responders (e.g., paramedics, police officers or fire-fighters). For example, operatives face the demands of rapid risk assessment, time-limited decision-making, and coping with unexpected developments, regardless of which emergency service they are supporting (Artman & Waern, 1999; Blandford & Wong, 2004). Additionally, EDC operatives share the issues experienced by other call-centre operatives, such as high workload, performance monitoring, and limited opportunity for physical movement (Norman et al., 2004; Snooks et al., 2008; Dean & Rainnie, 2009; Taylor et al., 2013). Stressors present in non-emergency call-centres are associated with negative physical and psychological outcomes for call-centre staff, including reduced job satisfaction, poorer work performance and increased emotional exhaustion (Norman et al., 2004; Farquharson et al., 2012; Rod & Ashill, 2013). Stress may also influence staff performance; increased stress in call-centre-based nurses has been associated with greater cognitive failures and differences in decision-making (Allan et al., 2014), and with an increased intention to leave (Farquharson et al., 2012). Finally, EDC employment also involves shift-work, which has been linked to increased health risks across a range of professions, including increased rates of cancer, obesity, cardiovascular disease, blood pressure, poorer sleep quality, burnout, depression, and anxiety (Harrington, 2001; KivimÄki et al., 2010; Wright, Bogan & Wyatt, 2013; Wisetborisut et al., 2014; Proper et al., 2016).

To date, literature reviews have focused on the sources and consequences of occupational stress that paramedics and other ambulance personnel experience (Sofianopoulos, Williams & Archer, 2012; Hegg-Deloye et al., 2014; Adriaenssens, De Gucht & Maes, 2015). In contrast, there has been no published review exploring the sources of stress that impact on psychological health when working in an EDC. Statistics from the United Kingdom show that of all staff groups across the National Health Service, ambulance service staff have the highest rate of sickness absence (Health & Social Care Information Centre, 2016), and that among emergency personnel, those working in the EDC have especially high rates of sickness absence and turnover (South East Coast Ambulance Service NHS Foundation Trust, 2015). It is therefore important to explore the stressors experienced by EDC operatives, as this knowledge could inform strategies to help minimise the impact of such stressors on the psychological health of those individuals who work in an EDC.

The objectives of this systematic review were therefore to investigate and synthesize available evidence relating to the psychological health of EDC operatives, and to identify key stressors that they experience. The specific review question was: what elements of working in the EDC do operatives identify as influencing their psychological health (e.g., reports of negative symptoms of stress, burnout, and mental health conditions, or reports suggesting strong emotional resilience and positive coping skills)?

Methods

This review was conducted in line with the PRISMA guidelines (see Supplemental Information 2 for checklist) and was registered on the PROSPERO database (http://www.crd.york.ac.uk/PROSPERO): registration number CRD42014010806.

Results

Studies included in review

A total of 2,358 articles were identified from electronic searching, of which 914 were removed as duplicates. A review of the reference lists of articles included in the review after full-text reading identified a further 72 articles that might potentially meet the inclusion criteria. Therefore, a total of 1,516 abstracts were retrieved for screening. During abstract review, 1,401 articles were excluded, leaving 115 articles to be assessed through full-text reading. After sourcing these for full-text reading, 99 articles were excluded for the following reasons: sample did not include EDC operatives (n = 71), findings were not related to psychological health or stress (n = 18), documents retrieved were unpublished articles or theses (n = 10). This resulted in 16 articles meeting the inclusion criteria. These details are summarised in Fig. 1.

Discussion

Research examining Emergency Dispatch Centre (EDC) operatives’ psychological health is limited. This narrative review identified that EDC operatives across different emergency services consistently reported their job as highly stressful, and this stress sometimes affected their psychological health. It also highlighted a lack of longitudinal studies exploring the long-term effects on psychological health of working in an EDC.

Workload demands and supervisory difficulties were frequent concerns. Although EDC operatives do receive supervision and training, some operatives considered their training and supervision to be inadequate, which they reported exacerbated their stress. Poor supervision, a lack of understanding by management, and the pressures of being monitored have also been identified as potential stressors amongst staff in other call-centre and medical settings (Deery, Iverson & Walsh, 2002; Dean & Rainnie, 2009; Taylor et al., 2013; Johansen, 2014).

Frustrations arose amongst EDC operatives from a perceived lack of control over their workload, and this might have implications for their wellbeing and retention, as perceptions of job control amongst non-emergency call-centre agents are related to job satisfaction (Grebner et al., 2003). Furthermore, an excessive and demanding workload is a common feature across call-centre work, and this may lead to emotional exhaustion and burnout (Deery, Iverson & Walsh, 2002; Dean & Rainnie, 2009; Rod & Ashill, 2013; Taylor et al., 2013).

The nature of the calls is another source of considerable stress. Although EDC operatives do not experience emergencies first hand, operatives can experience vicarious trauma as a result of some of the calls they handle. Research exploring the effects of job-related exposure to trauma in emergency department personnel (Lin et al., 2007; Adriaenssens, De Gucht & Maes, 2015) and trainee paramedics (Fjeldheim et al., 2014) suggests that such exposure can have negative impacts on health and wellbeing, and may contribute to burnout (Adriaenssens, De Gucht & Maes, 2015) and compassion fatigue (Van Mol et al., 2015). It seems reasonable to assume that EDC operatives are at risk of similar outcomes. The findings from this review indicate that some EDC operatives do indeed experience symptoms associated with negative psychological health and high levels of psychological stress, including increased alcohol use, disturbed sleep, and unwanted flashbacks related to calls. Similar symptoms, along with high rates of depression and post-traumatic stress disorder symptomology, have been reported in both trainee (Fjeldheim et al., 2014) and qualified (Hegg-Deloye et al., 2014) paramedics.

EDC operatives are therefore likely to be at risk of emotional exhaustion and burnout, which may contribute to high absence rates seen amongst this group (South East Coast Ambulance Service NHS Foundation Trust, 2015). Some EDC operatives experience conflict and abuse from callers, which could further contribute to burnout. Call handlers working for a telecommunications company who believed customers were more abusive experienced greater emotional exhaustion (Deery, Iverson & Walsh, 2002). Additionally, those who reported higher levels of emotional exhaustion also had higher rates of absence (Deery, Iverson & Walsh, 2002). Burnout rates in other emergency medical personnel are also high (Lin et al., 2007; Popa et al., 2010; Adriaenssens, De Gucht & Maes, 2015), although this can vary by context (Popa et al., 2010; Gokcen et al., 2013). Educational programmes may help to reduce compassion fatigue and burnout (Flarity, Gentry & Mesnikoff, 2013).

Some EDC operatives reported using strategies to mitigate some of the negative effects of workplace stressors; strategies included the use of emotion regulation and engaging in peer support. Some of the evidence from this review, however, suggests the EDC work environment does not always provide opportunities for sufficient peer support. Existing research from other emergency medical settings suggests that the peer support element of team working can be beneficial for managing stress and preventing burnout (Beaton et al., 1997; Halpern et al., 2012). Future interventions may therefore need to focus on increasing opportunities for peer support, to build resilience amongst EDC operatives.

It is clear from the review that working as an EDC operative is highly demanding, and that stress will be inevitable at times. Interventions in the form of cognitive behaviour therapy or mindfulness (Hülsheger et al., 2014; Querstret et al., 2016; Querstret, Cropley & Fife-Schaw, 2017) have been shown to reduce potential negative effects of working in highly demanding environments. Future research could explore how similar interventions might help EDC staff to cope effectively with work-related stress.

It should also be noted that despite the challenges of the role, and the potential risks for psychological health, the studies reviewed did identify some of the more positive aspects of the role. EDC operatives enjoy performing an altruistic role, and reported gaining emotional competence as they gained experience, with some operatives also experiencing post-traumatic growth. The EDC work environment is fast-paced, demanding, and varied, which operatives saw as a key reason they enjoy their work and remain in the role. Indeed, exploring why some operatives experience higher levels of role-related benefits and fewer negative effects on their psychological health might indicate potential areas to intervene with their colleagues who do not have such positive experiences.

The findings from this review therefore highlight the unique combination of challenges faced by EDC operatives. The role combines features of both regular call-centres and emergency settings. Operatives report facing a psychologically demanding work environment, and at times, the workload can seem relentless. Although some operatives appear to thrive on the challenge, a significant proportion of the EDC workforce report experiencing negative effects on their psychological health as a result of their work. Future research should focus on exploring whether workplace-based interventions can improve the psychological health of those EDC operatives who are negatively affected.

Limitations

Search strings were devised to capture a broad range of studies, and a number of common themes were identified. The diversity of EDC populations studied (across time, role, and location) means that the relative importance of each theme is likely to vary between each sub-population of EDC operatives; there were, however, insufficient publications to enable differences between the emergency services to be explored. As there is a lack of recent evidence in particular, the findings of the review are potentially both time- and context-bound. Results should be interpreted with caution as findings are based on a limited number of high quality studies and there was heterogeneity in study design. Nonetheless, there was evidence of consistency across studies, as the themes identified were supported by evidence from all three emergency services, suggesting that the findings of the review are likely to be relevant to all types of EDC operatives.

The review was intended to capture longitudinal and intervention studies, but none were identified during searching. The included studies do provide insight into the stresses experienced by EDC operatives, but findings are limited by a lack of data on long-term outcomes.

Conclusions

EDC operatives report experiencing stress as a result of their work, which appears to be related to negative psychological health outcomes, such as emotional exhaustion and burnout. There is, however, a lack of evidence exploring how EDC work-related stress affects operatives’ psychological health over the longer term. Furthermore, most of the studies reviewed only set out to explore potential negative effects on EDC operatives’ psychological health. It is therefore important for future research to explore the positive aspects of the role that operatives value, and to better understand the factors that may contribute to resilience and good psychological health amongst this group.

Future research should also aim to explore the relationships between EDC-related stressors and long-term psychological health outcomes. If longitudinal studies support the main findings of this review, that EDC employment can negatively affect psychological health, there should also be efforts to develop interventions aimed at minimising the impact of EDC work on the psychological health of EDC operatives.

Supplemental Information