Occupational stress represents a major public health concern, particularly among workers exposed to high cognitive, emotional, and organizational demands (1).

The work of ambulance drivers represents an essential component of territorial emergency systems and is characterized by high operational complexity and responsibility (1). This function requires not only specific technical skills, but also a continuous ability to manage critical situations, often associated with urgency, unpredictability, and significant responsibility in protecting patients’ lives. Numerous studies indicate that the health emergency context represents a high psychosocial risk work environment, in which workers, including drivers, may experience high levels of perceived stress, burnout, and impaired psychophysical wellbeing (2–4).

Ambulance drivers are exposed to multiple stressors: managing traumatic emergencies, intense emotional burdens, irregular schedules, and challenging environmental conditions. These factors, combined with patients’ responsibility for their lives, contribute to high psychological vulnerability (5–7).

Furthermore, recent evidence has shown that chronic stress and burnout in rescue workers are associated with sleep disturbances, worsening cognitive function, and increased risk of cardiovascular disease (8, 9).

Despite this evidence, the ambulance driver population remains relatively understudied compared to other healthcare professionals, such as doctors and nurses, despite similarly stressful working conditions (10). In particular, limited evidence is available on the combined role of perceived stress, individual characteristics, and work-related factors within an occupational health surveillance framework. In light of this, this study aims to analyze the levels of perceived stress in a large sample of ambulance drivers undergoing health surveillance. The specific objectives are: (a) to describe the distribution of stress in the population examined; (b) to analyze gender differences in PSS-10 scores; (c) to identify the main predictors of perceived stress through multiple regression; (d) to identify behavioral profiles through cluster analysis. This approach aims to outline a complex picture of the risk and protective factors associated with work-related stress, contributing to the international literature on the wellbeing of emergency workers (11).

The results of this study confirm that ambulance drivers represent a category at high risk of stress and burnout. Perceived stress levels vary significantly between subjects, with women reporting higher scores, a finding consistent with what has been observed in other studies of emergency workers (4, 13). Recent evidence from international contexts corroborates these gender-based differences. A cross-sectional study conducted in India during the COVID-19 pandemic found that female ambulance drivers and other healthcare workers experienced significantly higher levels of psychological distress compared to males, with distress associated with longer work hours, changes in work schedules, and direct involvement in pandemic response activities (14, 15). This study specifically identified longer hours of work (≥8 h/day), direct COVID-19 patient care, and high emotional exhaustion as significant risk factors for psychological distress among healthcare workers, including ambulance drivers (16).

Research examining female emergency medical services clinicians more broadly has documented that women face heightened risk for adverse mental health outcomes, including anxiety, depression, and post-traumatic stress disorder.

A recent cross-sectional study of Emergency Medical Service (EMS) clinicians reported rates of 34% for anxiety and 29.2% for depression among EMS personnel (17). Another mixed-methods study found that female EMS clinicians had high rates of probable anxiety (70.0%), probable depression (53.9%), and elevated burnout (40.9%), with workplace harassment and lack of support being common experiences (18) These disparities are influenced not only by the inherent stressors of emergency work but also by gender-based challenges in the workplace, including discrimination, lack of support, and concerns about appearing incompetent. Qualitative and quantitative data from female EMS clinicians highlight that discrimination, harassment, and insufficient workplace support contribute to adverse mental health outcomes and increased occupational burden (19). Additionally, lower leadership support and greater work-related concerns have been shown to mediate the increased risk of chronic stress-related psychological sequelae in women.

Among the main predictors of perceived stress identified in our study are seniority, health problems, alcohol consumption, and poor physical activity, all factors already highlighted in the international literature as determinants of psychological wellbeing (5, 20, 21). The relationship between work seniority and stress is particularly noteworthy. While experience typically serves as a protective factor, prolonged exposure to high-stress emergency situations can lead to cumulative trauma and emotional exhaustion. Recent findings from a Chinese study of 213 ambulance drivers demonstrated that occupational stress was positively correlated with burnout and negatively associated with sleep quality, with burnout partially mediating the relationship between occupational stress and sleep disturbances. This mediation effect accounted for 26.09% of the total effect, suggesting that chronic stress operates through burnout to impair essential recovery processes (2). Frontline ambulance staff in the United Kingdom, particularly paramedics and emergency medical technicians (EMTs), are most affected by burnout, with high prevalence and severity of both burnout and depersonalization. Recent systematic reviews and qualitative studies indicate that more than half of UK ambulance personnel experience significant levels of burnout, and up to 87% report moderate or high levels of depersonalization toward their work (22). These findings are consistent with broader evidence that occupational stress and burnout are highly prevalent among ambulance personnel, and that sleep quality is both a consequence and mediator of these relationships.

Perceived stress therefore proves to be a multifactorial phenomenon, influenced by individual, behavioral, and organizational elements. Physical activity emerges as a protective factor in our study, while alcohol consumption aggravates stress, findings that align with results obtained from studies on prehospital staff (11, 23). The protective role of physical activity may operate through multiple mechanisms, including stress hormone regulation, improved sleep quality, and enhanced psychological resilience (24, 25). Alcohol consumption as a coping mechanism may worsen stress responses and mental health. Longitudinal cohort data from UK healthcare workers show that increased alcohol use is associated with higher symptoms of depression, anxiety, and PTSD, particularly when used as a coping strategy in response to occupational stressors (26). Additional evidence from ambulance personnel indicates that drinking to cope is a significant risk factor for alcohol-related problems and is associated with higher levels of depersonalization and burnout (27). Neurobiological studies further support that stress and alcohol have bidirectional effects on brain networks involved in emotional processing, contributing to comorbid psychiatric illness and alcohol use disorder (28). A review examining the effect of ambulance clinicians’ wellbeing on occupational and patient safety identified that burnout, stress, poor sleep quality, and fatigue increase the risk of accidents and adverse events. The review underscored that these factors not only compromise provider wellbeing but also pose direct threats to patient safety and occupational safety in prehospital emergency medical services settings (29).

Organizational conditions, such as workload and supervisor support, significantly influence burnout risk and resilience (3, 10). The statement that 73% of EMS providers nationwide report burnout or compassion fatigue is supported by recent survey-based studies and systematic reviews, which consistently demonstrate high prevalence of burnout and compassion fatigue among U. S. EMS personnel, with rates ranging from 39% to over 70% depending on the measurement tool and population sampled (30, 31). The finding that 37% plan to leave the field within 5 years is corroborated by national cross-sectional analyses showing that intention to leave EMS within 1–5 years is common, particularly among those working overtime or multiple jobs, with financial dependence and job dissatisfaction as key drivers (32, 33). Nearly 60% of EMS agencies report insufficient staffing to meet emergency call demands is reflected in workforce studies indicating widespread staffing shortages and turnover, with stress and burnout as major contributors to attrition and inability to meet operational needs (32). 49% of paramedics work more than 40 h per week and many holds multiple jobs is substantiated by large-scale survey data showing that the majority of EMS professionals work over 40 h weekly, and a substantial proportion rely on overtime or multiple jobs to make ends meet (33). Only 27% of EMS providers meet recommended sleep guidelines, and 61% cite lack of time as a barrier to maintaining physical health is supported by systematic reviews and occupational health studies documenting poor sleep quality, high rates of fatigue, and lack of time for health maintenance among EMS clinicians (29). Recent studies on EMS workforce retention have identified burnout and stress as major contributors to high sickness rates and staff attrition, with the first 2 years of employment being particularly critical for retention. Stress and burnout are the most frequently cited reasons for leaving EMS, and younger, less experienced staff are at highest risk for early attrition (34). Evidence from intervention studies indicates that coping training programs can reduce emotional exhaustion levels among ambulance staff, with more modest effects on depersonalization and personal accomplishment. A systematic review of interventions targeting resistance and resilience among EMS clinicians found that mindfulness-based and coping-focused interventions were associated with reductions in burnout, particularly emotional exhaustion, at up to 6 months of follow-up, though effects on depersonalization and personal accomplishment were less pronounced (35). A quasi-experimental study of the FIRECARE program, which combined mindfulness, heart coherence, and positive psychology training for advanced life support ambulance staff, demonstrated significant reductions in burnout, primarily in emotional exhaustion, at 3 months post-intervention, with smaller or non-significant changes in depersonalization and personal accomplishment (36). These findings are consistent with broader evidence that resilience and coping interventions for healthcare professionals, including ambulance staff, are most effective in reducing emotional exhaustion, with more limited impact on other burnout dimensions. Gender-specific considerations warrant particular attention in prevention and intervention strategies. Women in EMS face unique challenges that extend beyond the inherent stressors of emergency work. Studies examining female EMS experiences have documented higher rates of workplace discrimination, sexual harassment, and concerns about being perceived as incompetent (18). Female paramedics report being 28.4% more likely than their male counterparts to fear appearing incompetent and therefore less likely to speak openly about mistakes, which can have significant implications for both learning and patient safety (37). Research from Turkey, where women comprise 72% of paramedics, reveals that female providers face gender discrimination, violence, and professional challenges that adversely affect their personal and professional wellbeing (18, 38). The intersection of gender-based stressors with the already demanding nature of emergency work creates a compounded risk for psychological distress among female ambulance personnel. Addressing these gender-specific challenges requires not only individual support but also systemic changes to workplace culture and leadership practices.

The mental health crisis within emergency medical services is further evidenced by data on post-traumatic stress disorder prevalence. A study from Saudi Arabia found that 26% of EMS personnel screened positive for PTSD, with exposure to traumatic events being a significant contributing factor. Interestingly, research suggests that PTSD in paramedics is not always caused by major traumatic incidents but can arise from smaller everyday events that trigger symptoms, combined with chronic organizational stressors such as excessive workload, pressure from management, and changing shift patterns (39). This finding emphasizes that prevention efforts must address both acute traumatic exposures and chronic organizational stressors. The prevalence of mental health issues among EMS personnel has profound implications not only for individual wellbeing but also for patient care quality, as psychological distress is associated with increased risk of clinical errors, communication failures, diminished clinical capability, absenteeism, and increased turnover.

Recent studies confirm that resilience, functional coping, and ongoing psychological support are key tools for preventing burnout and improving service quality (40, 41). However, access to mental health support remains inadequate. Barriers to accessing support include stigma, lack of time, and insufficient availability of services tailored to the unique needs of emergency personnel (42). Expanding mental health services and reducing barriers to access represent critical priorities for EMS organizations. Additionally, research has shown that supportive workplace policies, such as adequate paid sick leave, are associated with better job satisfaction and retention, suggesting that comprehensive benefits packages may serve as both a recruitment and retention strategy while supporting employee wellbeing. The findings of this study may have important implications for public health and occupational prevention. The observed associations are consistent and may translate into a significant population-level impact, considering large working populations and long latency periods. These findings support the role of primary prevention strategies aimed at reducing occupational exposures through exposure-oriented risk assessment, source control, and organizational interventions. These findings can contribute to risk prioritization and guide occupational preventive actions. Furthermore, future research should focus on longitudinal study designs with improved exposure assessment, including cumulative and mixed exposures, as well as the integration of biological markers and individual susceptibility factors to better elucidate causal pathways and improve risk stratification.

This study presents several limitations that warrant consideration. The reliance on self-reported measures introduces potential recall and social desirability biases, particularly concerning alcohol consumption, smoking habits, and physical activity. The PSS-10, while psychometrically sound, captures only subjective stress appraisal without objective physiological indicators. The single-center setting in Sicily limits generalizability to ambulance drivers in other geographic regions or healthcare systems. The sample consisted exclusively of drivers undergoing mandatory health surveillance, potentially introducing survivor bias by excluding those who had already left the profession due to stress. The modest explained variance in the regression model (R² = 0.045) indicates that unmeasured factors such as organizational climate, social support, specific traumatic exposures, and coping resources likely contribute substantially to stress levels.

Despite these limitations, this study provides valuable preliminary insights into stress profiles and identifies potentially modifiable risk factors for occupational health interventions: first, the high prevalence of stress and burnout among ambulance drivers necessitates routine psychological screening and early intervention programs. Proactive identification of at-risk individuals, combined with timely access to support services, may prevent the progression from stress to clinical burnout and mental health disorders. Second, organizational interventions must address modifiable workplace factors, including workload management, shift scheduling, adequate staffing levels, and supportive leadership practices. Recent evidence suggests that organizational commitment, peer support, and authentic leadership can attenuate work-related stressors among EMS clinicians. Third, gender-sensitive approaches to workplace policy and culture are essential, given the documented disparities in stress, mental health outcomes, and workplace experiences between male and female EMS personnel. The observed also that gender distribution, with a predominance of male participants, reflects the current occupational composition of ambulance drivers in the Italian Emergency Medical Services, where driving roles are still predominantly held by men. Future studies conducted in different organizational and cultural settings are needed to confirm these results. Leadership development programs that emphasize transformational and inclusive leadership styles may be particularly valuable in creating more equitable and supportive work environments.

The evidence collected highlights the need to implement multidimensional prevention strategies that integrate organizational (shifts, support, work climate) and individual (physical activity, reduction of alcohol consumption, coping training) interventions, with particular attention to gender differences and health factors. Given the documented workforce crisis, with substantial proportions of EMS personnel considering leaving the profession, urgent action is required at multiple levels, from local service provision to national policy. Future research should employ longitudinal designs to better understand the temporal relationships between occupational stressors, mental health outcomes, and workforce retention, as well as to evaluate the effectiveness of prevention and intervention programs in real-world EMS settings. Only through comprehensive, evidence-based approaches that address both individual and systemic factors can we hope to sustain a healthy, resilient emergency medical services workforce capable of providing high-quality care to communities.