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Education and Employment References Committee
31/07/2018
Mental health conditions experienced by first responders, emergency service workers and volunteers

DAWSON, Mr David Alan, Member, Paramedics Australasia

HAIGH, Ms Simone, Vice-President, Paramedics Australasia

[11:14]

ACTING CHAIR: Welcome. I understand that information on parliamentary privilege and the protection of witnesses and evidence has been provided to you. I now invite you to make a short opening statement and, at the conclusion of your remarks, I will invite members of the committee to ask questions.

Ms Haigh : Paramedics Australasia is the peak national organisation representing paramedics. Paramedics are best known for providing out-of-hospital emergency care throughout their work with various ambulance service organisations and may work in many environments, including community, industrial, military, hospital and university settings. Paramedics Australasia provides a voice in determining changes in health service provision, legislation and clinical practice are shaped and implemented to enhance the quality of patient care. We represent practitioners in matters relating to health policy, professional standards, education, registration and research.

Over the years, Paramedics Australasia has become increasingly aware from members of the mental health difficulties amongst the paramedic community. This prompted the organisation to form our Mental Health and Wellbeing Special Interest Group and, along with other organisations initiated the Survive and Thrive Symposium, focused on paramedic mental health and resilience. This symposium has been held every year for the last three years in three different states. These symposiums have been well attended and received by paramedics.

Our Mental Health and Wellbeing SIG aims to promote paramedic mental health and wellbeing. This is achieved through identification and articulation of mental health concerns for paramedics; promoting evidence based initiatives; promoting education and awareness; reducing stigma on mental health issues within the paramedic community; and encouraging open conversations regarding paramedic mental health issues. The group also aims to identify aspects of paramedic mental health that require more research and to encourage policy debate.

I'd like to thank the Mental Health and Wellbeing SIG chair, Lisa Holmes, and deputy chair, David Dawson for their work in putting this submission together. They have been vital in the whole submission. I'd also like to thank this committee for having this inquiry, and I would personally like to thank Anne Urquhart for listening to the concerns and being a key driver in this inquiry. I will now hand over to David.

Mr Dawson : I don't want to shock you but I have to tell you that I've never been a paramedic. I started work for the Ambulance Service in 1984, working at the Ambulance Officers Training Centre. I managed the training program there and it was my job to look after everything that was not ambulance—so no medical stuff or whatever. I did psychology, maths, science and stuff like that. So that's how I got to be there. In that year, I was involved in the survey mentioned by Scott Fyfe run by Dr Robyn Robinson. I was involved in a questionnaire kind of way but nevertheless I was involved. There were two more surveys, in 1993 and 2002, which I was involved with as well. Going back to what Scott said about the response rate, it was extraordinary. There was a 60 per cent response rate. That was unprecedented for a survey like that. So that was wonderful. After the first survey in 1986, the Victorian Ambulance Crisis Counselling Unit was established as a result of that work, and I served on the community management of that unit.

After that I went to work in Victoria University and my work involved trying to prepare student paramedics in a psychological kind of way for ambulance work. In late 2010 to 2011 I worked with the Victorian Ambulance Crisis Counselling Unit again to put together a survey, and it is that data we refer to in the submission that we put together. I am also using it in my PhD—and I am not that far away from getting it finished. I am also a research psychologist with AHPRA.

As part of my opening statement I want to comment on what I think are the main things here. You know about PTSD, so I don't need to go on about that. I will just say that in my study when I looked at the prevalence of PTSD in the Victorian paramedics the prevalence was smack bang with the international figures. The international figures show that paramedics have about a 14.6 rate of PTSD and mine was 14.5—so it is right there. This shows, I think, that paramedics are at risk of PTSD three times more than the general population and the rate is higher than the police and fire—not that I want to be in competition with them; it's just higher. So being a paramedic is a risk factor for developing PTSD.

The second thing I want to point out that I think is a major issue, from my study, is the level of suicidality, which involves suicidal thinking, suicidal planning and attempted suicide. There were a couple of other questions as well, and I can talk further about that if you wish.

The third one is problems with sleep. Sleep is just such a pervasive problem, and it's much worse in paramedics than it is in the general population.

There are two other issues that are not mentioned in the submission, which I'd like to raise, if I'm allowed to do that. One is: we looked at mental health issues across the workforce. We tried to identify if there were places that should be targeted. We looked at people by age and by where they worked in terms of region, as to whether they worked in a low-SES or high-SES region or rural and so on. We found no difference, really—or that what differences there were, were very tiny. The exception, though, is for PTSD. Rural paramedics are more prone to PTSD. The implication of that is: if you are going to put an intervention program together, it's going to have to be across the workforce. Apart from that exception, it can't particularly be targeted.

The other thing I want to mention is that I think it's useful and important to identify events that cause distress to paramedics. That was mentioned by someone this morning, and they talked about ramping, fatigue and workloads, and I can't remember what else. I looked at that in my study, too, and I can talk a bit further about that. The reason why I think it's important is: not all those things that cause the problem are trauma—life and death stuff. They are things that are subject to being manipulated by the organisation. They can be managed, to an extent—not all of them, but a lot of them can. In that way you could reduce the stress of paramedics. That's me—that's my opening part.

ACTING CHAIR: Thank you to you both. We'll start with Senator Urquhart.

Senator URQUHART: Can I just put on the Hansard my thanks to Simone for raising this issue with me. It has certainly started a conversation around the country that probably would have been hidden still, had that not been a conversation that we had, some time last year I think. So I want to recognise Simone in that, but also to recognise every other paramedic and say that it's actually okay to have a discussion about it. And to the employers out there: it's actually okay to have that discussion with your employees as well, and we should be doing that, because the more we bring these things out in the open the easier it is for people to be able to deal with the issues that they're facing on a day-to-day basis in their lives.

I want to turn to some of the recommendations that you talked about in your submission, and I'm particularly interested in age and region and there being no difference. I think you just talked about that. In the survey that you did, age and region didn't have any influence on where it was. I'd you like to talk a little bit more about that, because I would have always assumed that somebody in a more remote, rural region would have had issues where they didn't have the support of their peers around them. So can you just shed a little bit of light on why that is.

Mr Dawson : Yes. We looked at gender, sex, and age and marital status, education level, the regions—but our regions are very big, so they encompass regional centres—years of experience and remoteness. The fact is: we did find some differences that were statistically significant. But the point is: they were very tiny. They explained less than one per cent in the difference in the levels of mental health. So effectively it's not clinically significant, I suppose, or there's not such a big difference that you can say, 'Well, that group deserves more attention than another,' whereas, with the PTSD, I can't think of them off the top of my head, but I think it was about 2½ times higher in rural paramedics, or more likely to be happening in rural paramedics, than it was in the paramedics in major cities. So there were just no differences. That is a significant finding, I think, and it means that the thing's pervasive.

Senator URQUHART: Another one of your recommendations—and you just talked about it—was on sleep and sleep problems.

Mr Dawson : Yes.

Senator URQUHART: I think we all know that if we don't get enough sleep we can be pretty crabby and not function very well.

Mr Dawson : Yes.

Senator URQUHART: What's the difference with a paramedic not getting enough sleep? Talk about that. What does it mean?

Mr Dawson : There's no difference. If they don't get enough sleep, they're not healthy, like everybody else.

Senator URQUHART: Yes, but why is it so important?

Mr Dawson : Let me give you a sense of the size of the difference, perhaps, for a start. My study showed that 30.7 per cent of paramedics met the criteria for disturbed sleep—roughly 31 per cent. These are very large numbers, I think. Let me be precise. The comparable figure for the general population is 5.4 per cent, so it's roughly six times higher. So that's big.

The other measure that shows you that sleep is a problem is the typical question that is asked: 'Have you taken sleeping tablets in the past two weeks?' If you asked that of paramedics—I've forgotten the figure, but let's say it's about 18 per cent, and it's four per cent for the general population, so it's about six times higher for paramedics than it is in the general population. So that's the size of the problem.

If you want to ask what I think the cause of it is and what can be done about it, I don't directly know the answer to that. I can say that a lot of paramedics do rotating shiftwork, and rotating shiftwork is the worst kind of shiftwork. This is a report from the US National Institute for Occupational Safety and Health, I think. They found that people who do rotating shifts are much more likely to report psychological problems and physical health problems compared to other shiftworkers and the general population. I can't sit here before you and say that's the problem, but I'm fairly confident it's a contributing factor.

Senator URQUHART: It's part of the problem, yes. You talked about suicide, and you've touched on that within your submission. You have a recommendation there about developing suicide prevention programs that are evidence based. Can you talk a bit more about what you mean by that.

Mr Dawson : First of all, there are Australian guidelines about this. I'm not intimately familiar with them, but there are. Too often we just overlook these things that are out there already that are based on the evidence. There are two programs I know of that were quite startlingly successful. One was with the Houston Fire Department, and the other one was with the Montreal police. The Montreal police, particularly, measured very carefully the effectiveness of their program. I think I've got it in my submission. They looked at the seven years before they started the program. About six or seven police committed suicide in that seven years, and six years after that program started not one police person committed suicide. There was one suicide the year after that. So that's what I mean by the evidence base. They had an information program. They taught people how to talk about suicide. They put words in people's mouths: 'Talk to your colleagues. This is the question you can ask your colleague. If you're worried about them, here's the question you can ask. By the way, it doesn't do any harm to ask the question, and you're not going to make people commit suicide because you're asking them how they're travelling.' The third thing I think they did was to put together a range of resources that people could access to get support if they wanted to get support.

Senator URQUHART: Just further on research and reporting, are there good examples from across the country of how ambulance services are assisting paramedics to report?

Mr Dawson : I really don't know that. I've been out of the ambulance service for such a long time. But I have heard that Queensland has a good peer support program, and I've seen the strategic plan for Ambulance Victoria, which has all the right elements as far as I can see.

Senator URQUHART: I don't know whether you can answer this, but I'm going to ask you anyway, and maybe Simone can answer it; I don't know. How can we improve the culture, particularly in the middle management areas? We heard earlier—and I'm not sure whether you were in the room—that there are issues with processes being too onerous and/or not being followed at all. How does that process get dealt with?

Ms Haigh : I think it has to be driven from the top down. Some of the top are doing things, but I think a lot of education needs to come in for that middle management level, because they're getting it from the top and from the bottom. How you do that I don't know. I know that Ambulance Victoria have started doing that. Tony Walker has been very encouraging to his middle-management staff. For example, at a conference I heard him talk about how if in incident occurs the manager will call the person and say: 'What support do you need? We'll pull you off the road. We can give you a break. We can do all this other sort of stuff.' They're starting to proactively manage critical incidents and things like that. They are only in their early stages as well, but it seems to be going quite well.

Mr Dawson : I think that whatever you do in this particular area and to do with organisational change you have to measure the outcome. Paramedics can be surveyed as to the events that cause them distress. I can't think of all the things at the minute, but there are things like inappropriate management style—things management do or the organisation does, like not supporting them or whatever. You can measure how often that's happening—you can ask people in a survey how often that's happening—and come back two years later after you have done something to see if there has been a change in the level, because you want to be sure that you're getting a return on your investment.

Ms Haigh : I think that managers—an on-road paramedic talking about managers—are probably forgotten in the mental health space as well. Some of this culture may also be that they're broken as well. We have to remember that this is a whole organisation thing, not just the frontline staff.

Mr Dawson : Ambulance Victoria's strategic plan mentioned that management staff have high levels of mental ill health as well. Elsewhere I have read that one of the symptoms of PTSD is emotional numbness. If you are a manager who has become emotionally numb and are dealing with an employee who is not well, you may not be responding as well as you should do anyway, let alone to do with the culture and whatever.

Senator URQUHART: Let's talk about the impact of managerial behaviour on the mental health of paramedics. It may be for lots of reasons, but it can't be ignored, because at the end of the day they are the ones giving the directions, if you like. Can you point me to some examples of poor management practices, how they could be improved and what's being done now to try to overcome some of those issues?

Mr Dawson : No. I'm not close enough anymore to be able to identify particular examples in the ambulance service to answer your question, I'm sorry.

Senator URQUHART: We heard from the police association first thing this morning. The chief of police, the top officer in the state, the commissioner, wants to improve things. He wants to do everything and the officers obviously do, but there seems to be some blockage. How do you deal with that in the situation where you have direct management? I'm not having a crack at managers. I'm just trying to work out how you break down those barriers so those people at that level of vulnerability at the shop front and on the frontline can talk to those people.

Ms Haigh : The first thing that comes to mind is support and education. They probably have a lack of support and they do have a lack of education. They are the two things that just pop into my mind.

Mr Dawson : Yes, education. Perhaps again putting words in their mouths: 'This is how you talk to people. This is how you interact with people.' I suppose giving them some strategies on how to behave differently, because at the end of the day you want to change behaviour. Behaviour is something you can observe and see. People can observe their own behaviour and try to make a behavioural change. You can measure it as well. That's a very vague answer.

Senator URQUHART: It's a very difficult question too.

Ms Haigh : It also comes down to compassion as well and workplace compassion. I think in a lot of ambulance services at the moment we are suffering compassion fatigue. I think that's from all levels of ambulance. Maybe we need to take some time out and start to look at bringing compassion back into the workplace.

Senator URQUHART: I just want to go to the 10-point plan that's included in the Council of Ambulance Authorities' submission. How well is that being implemented? What can be done better? Is it being implemented well or is it just 10 points on a piece of paper at the moment?

Ms Haigh : Personally I think there are just 10 points on a piece of paper at the moment.

Senator URQUHART: Is there a driver within the Tas ambulance service to actually implement that?

Ms Haigh : I'm not here for them today. I'm unsure what's happening in Tas ambulance.

Senator URQUHART: Okay. I'll certainly ask that question of them.

Ms Haigh : But my role in Paramedics Australia is the first I've heard of it.

Senator URQUHART: You talked about the symposium Survive and Thrive. Can you just tell me a little bit about why that's been so important, why it has been successful. How many paramedics get along to that? And how is that actually improving the mental health of paramedics?

Ms Haigh : We started that after there was a spate of quite a few paramedic suicides a few years ago. We want to try and help give paramedics skills in how to become more resilient, how to talk to each other and how to reduce stigma, which is still the No. 1 problem.

Senator URQUHART: And when you say 'we', do you mean Paramedics Australasia?

Ms Haigh : We joined with the Australian New Zealand College of Paramedics to get together in a large coverage to try and get these symposiums out there. We've had, every year, over 150 people attend each symposium and we aim to have different stuff every time. The last one had workshops and things to do. The one before was in Melbourne and even had a PTSD dog and things like that so we try to mix it up and change it. But we also get key speakers to come and talk and even just real life speakers to come like Allan Sparkes, who is a police officer who had PTSD. He came and spoke at the first one. It's those real-life stories and the 'it's not a sprint, it's a marathon' sort of stuff that are really key to understanding, because people don't listen if it's not relevant. So we try and get those people to come in who are relevant and who seem to be well received.

Senator URQUHART: So that's something that's obviously successful that's run by an organisation. Do the ambulance bodies that employ the paramedics have any involvement in that?

Ms Haigh : No.

Senator URQUHART: So is there an interest from them as to what's happening with those?

Ms Haigh : Last year they sent quite a few. It was in Queensland this year and they sent quite a few. But generally, no. It's not advertised to staff. It is only through Paramedics Australasia.

Senator URQUHART: It sounds like it's something that would be useful to have a much larger contingent of ambulance bodies.

Ms Haigh : It is supported by CAA and the National Council of Ambulance Unions.

Senator URQUHART: But not by the departments in each of the states, which is probably where it needs to be driven from.

Ms Haigh : But they would see their support through CAA rather than individually.

Senator PATRICK: Mr Dawson, you talked about a systematic review of rescue workers. Was that your PhD thesis that you were referring to?

Mr Dawson : The systematic review was an international study done on levels of PTSD in paramedics.

Senator PATRICK: It wasn't referenced. It wasn't footnoted so I was just trying to establish what that was because then you go on to mention other statistics, which, I presume, came from your own research.

Mr Dawson : Sorry. Yes, I was comparing my statistics from my study with the statistics in that review and that is the review that reported the 14 per cent on average figure for levels of PTSD in paramedics across the globe. I said that my figure was about the same. So this population is just consistent with the other populations in in that review.

Senator PATRICK: It wasn't footnoted. Maybe there's a reference somewhere else. I have an engineering background, and all solutions start with data. So how have you got access to this data? For example, I know you've got some information about the South Australian Ambulance Service and you also had some information out of Queensland, I thought. How did you get access to that information? Was it publicly available? Or was it through academic processes?

Mr Dawson : That was written by a member from South Australia. A call for contributions to the submission was made, and the person from South Australia put that section together.

Senator PATRICK: Was that someone on the inside?

Mr Dawson : She works with the South Australian ambulance service.

Senator PATRICK: A lot of this data seems to be quite rare to get access to, either because the studies haven't been done or because a study has been done and maybe someone didn't want to communicate the data.

Mr Dawson : The South Australian stuff came from the person from South Australia. The numbers on mental health problems probably came from my PhD or from making comparisons with published data.

Senator PATRICK: How did you get access to that data for your PhD?

Mr Dawson : I did a survey in conjunction with the counselling unit from Ambulance Victoria in 2010-2011, and I put together the questions. We put questions about suicide on there, for example, because no-one had and we thought we should ask this question. It wasn't so big on people's minds at that time, but I happened to come across a Norwegian study on suicidality in Norwegian paramedics and so we used the same questions from that study in our survey. The survey was organised by the Victorian ambulance counselling unit in 2010. I put the survey together and analysed the data.

Senator PATRICK: Don't you find it unusual that it appears as though a lot of these entities understand there is a problem, but they're not measuring the quantum?

Mr Dawson : I agree absolutely. Measure everything! I had a statistics lecturer which said, 'If it exists, you can measure it.' I thought that was a very brave thing to say.

Senator PATRICK: Sure, but the deal is that an organisation that takes responsibility for its people will expend money to solve problems related to their people. In principle, you've had to generate this data yourself. There's no real repository of data that you can draw on to compare state versus state.

Mr Dawson : Correct.

Senator PATRICK: Noting you don't know who the person who contributed to that submission was, could you on notice provide the committee with where the source of that information came from, whether it was public or internal.

Mr Dawson : I can ask. I really want to but can't remember her name.

Senator PATRICK: It's okay. Take it on notice and get back to us. The other thing is you mentioned that, in terms of suicide rates, for every suicide there were 20 people who had attempted.

Mr Dawson : It was 20 to 30, yes.

Senator PATRICK: That's an international study.

Mr Dawson : No, that's Australian data. I think it's from Lifeline. There's another study published by someone called De Leo, an Australian from Griffith University. He says it's 23 attempts for every successful suicide. It ranges between 20 and 30. It's those figures that led me to the conclusion that attempted suicides of paramedics were probably underreported because the coroner said that there were seven or eight suicides in a seven-year period. If for every suicide there are 20 to 30 attempts then you would expect to have had a level of between three and five attempts reported by paramedics. In my study, only two reported attempting.

Senator PATRICK: It also doesn't seem consistent with the ratio of PTSD and the ratio between what happens in the ambulance service and what happens in normal, everyday life.

Mr Dawson : Correct. Within my study, if you have PTSD, you're 3½ times more likely to be thinking about suicide then you are if you don't have PTSD, which is a nasty comorbidity.

Senator DUNIAM: Looking at page 6 of your submission and the recommendation around screening to be 'implemented to monitor the mental health of employees of first responder organisations', you refer to a couple of what appear to be online mental health tracking services, myCompass and Mindgauge. How do they operate?

Mr Dawson : I know more about myCompass, so I'll speak to that. Mindgauge is similar. If you go to their websites, they will ask you a series of questions and they might suggest some course of actions. The questions might ask if you have some depression or a broken relationship or whatever it might be—I can't remember exactly what it is for the minute—and then it will direct you off to some modules of information and activities you can do to help address those problems. There are usually half a dozen to eight modules on each kind of issue they might develop, and you get feedback on your responses to those online teaching modules. Not only that; they send you little questions on your phone, tablet or whatever to rate certain things. They might ask questions related to depression, anxiety or whatever the issue is. They keep track, and you have a little graph of how you're going. If you were to fall down, there would be an algorithm stating you've got a level of depression which needs addressing and they'd send you off for another module on their website to try and address that problem. It's completely online. It's completely anonymous, and the research indicates—and I don't want to say this—that, for mild to moderate problems, it's as effective as face-to-face counselling; not for severe problems, but for mild to moderate. This is the research. myCompass is from Black Dog, and it's done with the University of New South Wales or whoever—I'm sorry, I can't remember.

Senator DUNIAM: Is myCompass something that an employee or an individual can just opt in to use? Have you observed it in an organisation where they've employed it—

Mr Dawson : No, anyone can use it—it's government funded by the way. These online programs can be quite good because you could go to the first page and straightaway get a series of questions and get feedback immediately as to how you where you stand with respect to that particular issue. It's the anonymity and the instant feedback that are useful.

Senator DUNIAM: Have you observed any of these sorts of programs used in organisations in the way you suggest they could be?

Mr Dawson : I haven't observed it, but I know that there's been work done on that. I know there's research available on how effective they are. I just can't remember if there's been any research about particular organisations, if that's your question.

Senator DUNIAM: Perhaps you could take on notice—I'm sure we'll provide that question formally to you—if there is any evidence pointing to the use of those programs. In that same recommendation on page 6 of your submission, you said:

Issues around employee concerns about such a program would need to be addressed.

Do you have any advice on how to address that?

Mr Dawson : Make it so it's confidential and anonymous, and no threat. I put that there because these online things are anonymous but you can contact the people who run them. I doubt it's specifically for them, but they can make sure that they've got stuff there for those people. The key issue is that it's confidential and that you get feedback straightaway. You get things to do to help address the problem, and no-one need know about it but you. I think that other people knowing you've got a mental health problem in the first responder space is still a problem—as much as we wish it wasn't, I think it is.

ACTING CHAIR: It's a stigma problem.

Mr Dawson : Indeed—that's what I mean, yes.

ACTING CHAIR: One of the other recommendations—and sorry I'm using a different printed version—talks about the recommendation that ambulance services follow the Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder. These guidelines include the recommendation that:

… populations at higher risk of PTSD are screened. That is, making the effort to find cases of PTSD in the population at risk.

Has this happened in any other jurisdiction that you know of? Are there any examples you can give us?

Mr Dawson : The Australian Defence Force does this.

ACTING CHAIR: Can you tell us how they do it? Have you got any further information on this?

Mr Dawson : I've only got what's in the public domain. First of all, the recommendation comes from the Australian Centre for Posttraumatic Mental Health, now known as Phoenix. They were engaged to come up with these guidelines and they've come up with two editions of them. I could be lying, but I think the Defence Force assess their people when they return from deployment, and some weeks and some months after deployment, so at least three stages along the way. Because we know that people can develop PTSD some months after the precipitating events, they screen at those intervals. What they use to screen, I have no idea. Part of the reason for screening is it's difficult to predict who is going to get PTSD or any other mental health problem, for that matter. So the only option you've got really is screen to see if you can find problems and find people who have got problems, because sometimes people don't even know themselves that they've got the problem.

ACTING CHAIR: That recommendation also talks about a mental health first aid 12-hour course for educating individuals on mental health prevalence, stigma, illness support and self-care. Can you talk to us about the importance of what that is? The recommendation is that it be delivered across all first responder organisations, I noticed as well.

Mr Dawson : That was added by Lisa, our chair. The key thing about the mental health first aid programs is that they give people the tools for how to react and how to deal with situations at the time. It's mostly to sort of withdraw from the situation, give yourself time to recover, talk about it with colleagues—that kind of thing. Also they teach you how to identify certain kinds of mental health problems, like depression, anxiety, schizophrenia, delusions and so on, so people have some knowledge of what to look for in themselves and in their colleagues. They typically say that when you've experienced a traumatic event you can expect some reactions, and this is normal, but they're not normal if they go beyond a particular time—usually six weeks. So basically they give people those tools to make those evaluations of their own mental health and take action if things haven't changed after a certain period of time. That's my understanding in a nutshell.

ACTING CHAIR: Is that linked to earlier on in the Paramedics Australasia submission, where it says:

Research has also found that paramedics and students feel unprepared for the mental health challenges of the profession and agree that inclusion of mental health in accredited undergraduate degree programs would aid this.

Is that part of that same thing or something different and separate?

Mr Dawson : I think the thing about the preparedness of students was a separate issue. It was identified as an issue. Different organisations will deal with it differently, with things like a stress management course or a mental health first aid course or whatever, as long as it's something that gives people the tools to monitor and manage their own mental health.

Ms Haigh : Anecdotally, what's happening at universities isn't enough at the moment. That's just anecdotally, from what we see from talking to people.

ACTING CHAIR: So they're not getting enough support before they actually go out into the field?

Ms Haigh : Not enough understanding and learning about mental health particularly and self-awareness and awareness of your colleagues. Speaking from my own personal experience, someone may have an issue, but you just go, 'Oh, that person's having a bad day.' Unless you see a pattern or unless you know what to look for, how can you help someone?

Mr Dawson : In our course at Victoria University—I wrote the mental health for paramedics subject there—we give them the tools. We give them a list of questions they can take away with them to assess their own mental health. We say to them, 'Do this every month or every six months, but do it regularly.' We help them to put together a suicide prevention plan which says, 'If you're feeling suicidal, here are some things to do,' so they've got a course of action to take should they feel suicidal. We hope they never do. We quite explicitly teach people to look for certain things in themselves to help manage it.

Ms Haigh : beyondblue are also online and have an app about safety planning for suicide.

Mr Dawson : That's the same thing.

Ms Haigh : Yes. I've personally tried to push on the PA social media that people need to go and have a look at these things now because when you're in a crisis that's not the time to try to work it all out; you need all of that there for you.

Senator O'NEILL: That's not a requirement, is it?

Ms Haigh : No, not a requirement.

Senator O'NEILL: And it's not a protocol or procedure in place.

Mr Dawson : Speaking about the online things, there's an online resource that people use. You can go online and put together a little plan in your own time—you can take a day to put it together. It's always there online or you can print it off, so you've got something to do and you have a course of action. Basically what it does is give things for people to do until they've reconsidered.

Ms Haigh : It gives people hope. That's what happens with suicidal people. They have issues from their past, or whatever it is, and they get to a point where they don't have any hope for the future. So it's trying to get that mindfulness and get them back into the present to try and break that rumination and those ideations. So the safety plan will have things like reasons for living and all that sort of stuff—your dog or whatever.

Senator URQUHART: Your mum.

Ms Haigh : Your mum, your family, your activities or anything like that. You may have a little box of things that you can open up when you're feeling like that. It might be photos or mementos or things like that. So that's the aim of that sort of stuff.

Senator URQUHART: These are really things that you could do right now.

Ms Haigh : Absolutely. We could all do it right now.

Senator URQUHART: While we're all sitting around gazing at our navels, building up procedures and that, these are really hands-on tools that are available now that could be implemented by everyone.

Ms Haigh : Exactly.

Senator O'NEILL: I want to give you a chance to put a little more on the record, Mr Dawson. Thank you, Ms Haigh, for your civic action in generating this inquiry. It's a really significant thing. It's a great part of our democracy, but only if somebody listens to you, so good on Senator Urquhart. I want to give you a chance to put on the record some further information about suicidal thoughts, plans and attempts, which you spoke to in your opening. I also wanted to ask if there is a research base around risk and protective health factors for this particular workforce if you're aware of any of that work.

Mr Dawson : I can't recall. I have read things about risk factors, but I can't recall them at this moment. I'm sorry.

Senator O'NEILL: Okay, that's fine.

Mr Dawson : But I can talk about the suicidality stuff. Just stop me if I go on for too long. As I said, when we put this survey together, we knew of the study done with Norwegian paramedics and we used the same questions. I'm going to tell you three of them, because they're the three most important ones. People have criticised these questions, by the way, because they are very general. One question was, 'Have you thought of taking your life, even if you would not really do it?' That was to measure suicide thinking. It's been accused of being a vague question, because you could have a whole range of things. It could be very severe thinking or it could be just mild thinking. Another one was, 'Have you reached the point where you seriously consider taking your life and even made plans for how you would go about it?' So that's making plans. The other one was, 'Have you made an attempt to take your life?' It put a time frame on it: 'Have you done this thing in the last year, the last month or ever in your life?' You've seen the figures in my submission about the whole thing.

Senator O'NEILL: Yes.

Mr Dawson : I don't need to go through them again, I guess. But I will say this: we asked people, 'Have you thought about suicide and have you made a plan?' but we don't know exactly what they are thinking and what they're planning. This was almost like a pilot study in a way. We had never done this before. We just ask these questions so we could make comparisons with the Norwegian paramedics, because there was no comparison we had at the time to make it with. So we don't know what paramedics are thinking. Maybe they are just talking about suicide cases they've been too. They might say, 'Well, that person committed suicide that way, and I've been thinking about it.' Then they might say, 'Well, I wouldn't like to go like that,' or, 'I would like to go like that.' So is that a plan? The question hangs in the air, which is really unfortunate. I actually think it's quite imperative we do some more work in this area.

Senator O'NEILL: Yes.

Mr Dawson : If we know what they're thinking and what they're planning—of course, this is not just paramedics; it's anybody—then we can make more effective interventions and prevention programs.

Senator O'NEILL: Yes.

Mr Dawson : We can help people. We can say to people, 'These are the kind of thoughts that paramedics have'—or firefighters or cooks or whatever—'and here's another way of thinking about it,' or, 'Can you think of alternative ways of thinking about this situation so we can help ameliorate the effects of that thinking?' I think this is the main thing that we need to do out of that.

Senator O'NEILL: Thank you. If you could you take on notice any research that you can discern about risk and protective factors that are particular to first responders, I think it would be very interesting to see if there's any work being done on that.

Mr Dawson : Sure.

Senator O'NEILL: I take you to a statement that you made in passing that I think goes right to the nub of what we're actually looking at, and that's about life incidents that are death or trauma as opposed to system dimensions that are part of what they've been calling the bucket today. One is an uncontrollable factor. The other clearly is a controllable factor but might be dependent on particular values sets or budget constraints that are creating a higher risk context for first responders.

Mr Dawson : I tell you what we did in this particular survey. We had a list of events that paramedics found to be stressful. We derived those from the previous surveys I talked about in Victoria. There were about 80 of them, I think. This time around, though, we asked paramedics to assess each event by rating its severity and how often it happened. Just by luck, I brought a list of the top 10 of these things with me. When you ask people to rate severity, you get things like low work morale and sleep disturbance, but you also get dealing with the death of children, having their life threatened and witnessing the death or injury of a colleague—that kind of stuff; that highly traumatic sort of thing. When you talk about frequency, you get sleep disturbance, interruption to meals, ramping—although I don't know if ramping is on this list—hospital bypass, poor drivers on the road; you get all that sort of thing. To get a sense of the overall impact of these events, you can multiply the severity score by the frequency score. When you do that, all those terrible trauma things fall away. Now I'm not for one minute trying to suggest they're not important. They are important and they need to be dealt with. They're critical events that people have had that they need to deal with. But the thing is: we've got low work morale coming out as having a higher impact. Interruption to meals, patients who abuse the system, hospital bypass, work overload, too much emergency work, not having the time to stop between calls, having a say in decisions that affect my work—the organisation has some power to change that list. There is some room for movement, I think. There are resource problems, perhaps, but they're not an immovable object; they are movable.

Senator O'NEILL: To be clear, Mr Dawson, are you giving evidence to say that the systems are more responsible for the stress levels, the anxiety, the suicidality—

Mr Dawson : No.

Senator O'NEILL: I need to be clear about what you're saying.

Mr Dawson : I'm saying: when you ask paramedics what things they find to be stressful, they rate these events as being stressful, and they rate them in these ways. I'm saying that it's the organisational things that have an impact on them. Now I can't then go and say, 'Well, that leads to the suicidality,' but it sure doesn't help your mental health. So I cannot sit before you and say, 'If A, then B.' I cannot do it.

Senator O'NEILL: So you can't make a causal link.

Mr Dawson : No.

Senator O'NEILL: But you can clearly indicate that there are critical incidents—traumatic events—that we automatically home in on and say, 'They are the things that are causing an increase in suicidality—and, sadly, suicide completion—and representation with PTSD in this group of people.' We all think that. But your evidence today suggests that it's not just that. In fact, we don't know quite the balance between whether it's those critical incidents or the ongoing drag of the resource-deficit system failure of responses—just the griminess of working in a system that is under-resourced—that is creating the context where, perhaps, these other critical events, which are the ones we home in on, are more important. This one, because it's so constant, may be more important than the incident.

Mr Dawson : I think that it is important because it's so constant, but I don't have the evidence to say to you that there's a cause-and-effect thing here. I just don't have it.

Senator O'NEILL: But there's an interplay regardless, isn't there?

Mr Dawson : Yes, absolutely, and I can say to you that paramedics will rate these things as having a high impact on them. And I can say that I think some of those things can be managed.

Senator O'NEILL: I'm very, very interested in that systems response capacity to reduce the impact of an unhealthy workplace. But there's one other thing that I want to go to. There are often performance criteria, and we had a conversation about the top-down, the bottom-up and this caught-in-the-middle management. You mentioned compassion fatigue, which might be manifesting itself in people's emotional numbness and incapacity to respond, because usually you don't get up to management until you've had a fair load of exposure yourself. In that middle part, we've heard about different emergency services. Are there key performance indicators that demand that people in middle management understand and take action about their own mental health and wellbeing and understand and take action about the mental health and wellbeing of the people that they care for? Or is that just an extra thing you do in addition to the job you get paid for?

Ms Haigh : My observation is that it's extra. It's not a KPI.

Senator O'NEILL: It's not your core business.

Ms Haigh : No. That's just my observation.

Senator O'NEILL: That takes me to sense of belief. We've heard this about the police. I know that you're not here to represent the police, but the old culture and the new culture is the way it was characterised this morning. I've done a bit of research myself and it's very difficult to displace people's belief systems. You can create all sorts of systems around them, but once there are belief systems in place and they don't think that looking after people's mental health is their work then it's very difficult to get that sort of cultural change that we've been talking about today. Do you have or are you aware of any research into cultural practices of resistance to change in terms of creating mentally healthy workplaces?

Mr Dawson : I can think of an example that I know of, but I'd have to do further research to get the details of it. It's the City of London Police. It was actually on a Catalyst program. That's how I know about it.

Senator O'NEILL: Oh, great. Thank you.

Mr Dawson : I think it was in 2008. I'm operating from memory here, but they measured things that people were doing. So it was a performance indicator. They surveyed staff on a certain list of things, like this list here, that were causing problems and stress for them. Over, I think, a two-year period they reduced their stress rate by 30 per cent or something like that. It was a huge reduction and saved a lot of money. I'll stop there before I start telling lies, because I can't remember any more.

Senator O'NEILL: That's very helpful. There clearly is an interplay in the reality of dealing with traumatic events, but a lot of the evidence we've heard today is about cultural practices that are exacerbating people's anxiety in their workplaces.

Mr Dawson : One thing I remember in this program is that part of it was to make managers accountable for the things that were happening with their staff and when staff were surveyed in their area about particular things if that level hadn't changed then they were held accountable for that lack of change or whatever it was. So that accountability was in there somewhere.

Senator O'NEILL: If you don't measure it, it's not valuable. That's the problem. Sadly, there are lots of jobs that people don't think matter very much until they need them. It's like in most households not replacing the toilet paper. People forget about those jobs that somebody else does.

Mr Dawson : The hygiene factor, they call it.

Senator O'NEILL: Yes, exactly. Thanks very much.

ACTING CHAIR: The committee will now suspend.

Pr oceedings suspended from 12:07 to 13:08