Emergency medical service (EMS) ambulance employees play a critical role in emergency healthcare delivery. However, work-related experiences can compromise their mental health and job satisfaction. Despite available supportive services offered by EMS organizations, employee uptake remains low, while mental ill health and suicide rates remain higher than those of the general population. Understanding barriers to and enablers of such support is crucial for addressing factors that connect employees with the services designed to help. This systematic review identified 34 relevant articles and utilized an innovative process of integrating quantitative and qualitative aspects of the primary and gray literature to provide a qualitative synthesis of barriers and facilitators as perceived by EMS employees. Themes of employee (in)ability to ask for help, tailored person-centered support, and education and training about mental health were overarched by organizational culture. Barriers included perceived organizational obligation rather than genuine care, alongside machismo and stigma. Enablers included valuing and acknowledging employee risk by providing time and normalizing support utilization at work. Reframing machismo from dominance, competition, and toughness to respect, perseverance, and courage; promoting adaptive coping; and providing time and training were essential. Future research should aim to understand the factors influencing employee utilization of supportive interventions based on these themes.

Introduction The COVID-19 pandemic is exacerbating a wide range of symptoms of poor mental health among emergency medical service (EMS) ambulance populations. Evidence suggests that using organisational support can improve employee outcomes and in turn, patient outcomes. Understanding why EMS staff do and do not use support services is therefore critical to improving uptake, ensuring equitable access, and potentially influencing workforce well-being, organisational sustainability and patient care delivery. This systematic review aims to identify what support is available and any perceived barriers and facilitators to accessing and utilising organisational support. Methods and analysis Searches performed between 18 February 2022 and 23 February 2022 will be used to identify studies that report barriers and facilitators to EMS employee support among all government/state commissioned EMS ambulance systems. Electronic databases, AMED, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, EMBASE, EMCARE, HMIC, Medline and PsycINFO will be searched. All relevant English-language studies of adult employees of government/state commissioned EMS ambulance organisations published since December 2004 will be screened and relevant data extracted by two independent reviewers. A third reviewer will resolve any disagreements. The primary outcome is the identification of perceived barriers or facilitators to EMS staff using organisational support for mental health. The secondary outcome is the identification of supportive interventions offered through or by ambulance trusts. Study selection will follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the methodological quality of included studies will be appraised by administering rating checklists. A narrative synthesis will be conducted to report qualitative and quantitative data and will include population characteristics, methodological approach and information about barriers and facilitators. Ethics and dissemination Ethical approval is not required because only available published data will be analysed. Findings will be disseminated through peer-reviewed publication and conference presentation. PROSPERO registration number CRD42022299650.

After losing a colleague to suicide last year, Sasha Johnston advocates for paramedic mental health. In this comment, she shares her personal experience of how being a paramedic has impacted her mental health, and how she has dealt with it. She also importantly shares her perspective about why, ‘it's OK not to be OK.’

Background: Out-of-hospital cardiac arrest patients with pulseless electrical activity are treated by paramedics using basic and advanced life support resuscitation. When resuscitation fails to achieve return of spontaneous circulation, there are limited evidence and national guidelines on when to continue or stop resuscitation. This has led to ambulance services in the United Kingdom developing local guidelines to support paramedics in the resuscitative management of pulseless electrical activity. The content of each guideline is unknown, as is any association between guideline implementation and patient survival. We aim to identify and synthesise local ambulance service guidelines to help improve the consistency of paramedic-led decision-making for the resuscitation of pulseless electrical activity in out-of-hospital cardiac arrest.Methods: A systematic review of text and opinion will be conducted on ambulance service guidelines for resuscitating adult cardiac arrest patients with pulseless electrical activity. Data will be gathered direct from the ambulance service website. The review will be guided by the methods of the Joanna Briggs Institute (JBI). The search strategy will be conducted in three stages: 1) a website search of the 14 ambulance services; 2) a search of the evidence listed in support of the guideline; and 3) an examination of the reference list of documents found in the first and second stages and reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses. Each document will be assessed against the inclusion criteria, and quality of evidence will be assessed using the JBI Critical Appraisal Checklist for Text and Opinion. Data will be extracted using the JBI methods of textual data extraction and a three-stage data synthesis process: 1) extraction of opinion statements; 2) categorisation of statements according to similarity of meaning; and 3) meta-synthesis of statements to create a new collection of findings. Confidence of findings will be assessed using the graded ConQual approach.

Background: Ulcerative colitis (UC), a chronic inflammatory bowel disease, causes stomach pain, diarrhea, and rectal bleeding. The exact cause is unknown, but it is thought to involve genetic, environmental, and psychological factors. Some people experience annual flare-ups without obvious reason. This article adopts a theory-driven approach to consider how and why past traumatic events may contribute to annual flare-ups. Methods: We applied learning theory, which explains the development of re-experiencing phenomena in post-traumatic stress disorder (PTSD), to better understand the occurrence of annual flares in patients living with UC. Results: Two possibilities emerged in which associative learning may contribute to annual UC flares. First, flare-ups could be a physical response to sensory cues in the present that overlap with trauma experienced at the first onset of UC. Annual episodes may strengthen the UC flare as a learned physiological response to trauma reminders. Second, flare-ups may result from elevated stress due to trauma re-experiencing at anniversaries. Sensory features of the initial UC trauma may be associated with strong reactions, which generalize to similar stimuli, triggering re-experiencing symptoms and increasing psychological stress. Elevated stress raises glucocorticoid levels, promoting UC-specific inflammation. Stimulus discrimination from cognitive therapy for PTSD may help to over-ride the associations that have formed between sensory features of past trauma, linked reactions, and similar cues in the present. Conclusions: Research is needed to understand how traumatic events influence the onset and recurrence of ulcerative colitis, as well as the potential benefits of stimulus discrimination for reducing the frequency of annual flares.

Introduction Emergency Medical Service (EMS) personnel experience elevated levels of psychological distress, trauma exposure, and mental ill health than the general population and other NHS staff groups. Despite the availability of support services, uptake remains poor due to stigma, fear of negative career consequences, workplace culture, and a lack of time at work. EMS-SHIELD (Supporting Health, Improving Employee Life and Duty), is a structured peer-led 1-hour session, scheduled during work hours to promote reflection, well-being check-ins, and signposting to support resources. Preparatory studies suggest this approach aligns with EMS professional identity, organisational culture, and employee norms favouring peer support. Methods A two-arm, cluster randomised controlled feasibility trial will assess recruitment, retention, intervention delivery, and trial procedures in one UK NHS ambulance service in Southwest England. Approximately 128 paramedics working across four ambulance stations will be invited to participate, targeting a recruitment rate of at least 50%. The four stations (two urban, two suburban) will then be randomised (1:1 by station) to EMS-SHIELD (intervention: dedicated time at work with signposting to relevant support resources) or usual practice (no dedicated time at work; unchanged access to standard support services). Trained peers will deliver EMS-SHIELD with fidelity monitored using standardised checklists. Questionnaires will be collected at baseline (pre-randomisation), 4–6 week post-randomisation, and 3-months post-randomisation. Primary outcomes include feasibility metrics (recruitment, retention rates, fidelity, questionnaire completeness), alongside acceptability metrics (session attendance and qualitative interviews exploring experiences). Secondary outcomes provide preliminary estimates of well-being, post-traumatic stress disorder symptoms, perceptions of organisational support, attitudes towards help-seeking, trauma exposure, health-related quality of life, and resource utilisation. Analyses will be descriptive with confidence intervals for feasibility metrics, and qualitative data will be examined using reflexive thematic analysis informed by behaviour change frameworks. Discussion This study will determine whether dedicated time for structured peer reflection in work hours is feasible and acceptable in a live EMS setting and whether trial procedures and health economic data collection are practicable. Findings will inform progression to a larger definitive trial to examine effectiveness for improving employee mental health and perception of organisational support at work, alongside cost-effectiveness evaluation. Trial registration The protocol for this study has been registered with the ISRCTN register: https://doi.org/10.1186/ISRCTN12172690; date of registration: 6th November 2025.