Introduction
Healthcare services are at a breaking point, with personnel fatigue and intent to leave at high levels [
1]. An increase in personnel intent to leave is also noticeable among the paramedic profession [
2‐
4]. Although catalysed by healthcare reforms and global pandemic, evidence suggests this is not a novel trend. From a healthcare service perspective, emergency medical services (EMS) is a specific context; paramedics are often highly trained healthcare professionals on the front lines, involving autonomous decision making with limited outside hospital resources while working in unpredictable environments under emotional pressure [
5‐
7]. All the while, paramedics are confronted with a variety of stressful elements [
7,
8] or job demands, that is, those aspects of the job, either social, organisational or physical requiring sustained mental or physical effort and leading to increased stress and burnout in their work [
9].
A paradigm shift regarding the role of EMS and paramedics, from traditional critical live-saver and transporting towards more specialised healthcare service providers [
10], accompanies a certain level of expectations, both societal [
10,
11] and from within the profession itself [
11]. Consequently, paramedics more often require both broader and deeper competencies to perform their daily clinical work, with wide variations in the complexity of patient encounters [
12,
13]. Therefore, an increasing number of paramedic professionals hold a university-level degree [
13‐
15]. Meanwhile, clinical patient situations that paramedics might not necessarily have the tools, knowledge or guidelines to handle often involve patients presenting complex clinical or social problems [
16]. This broad responsibility correlates with a sense of helplessness or inadequacy among paramedic professionals [
7]. Inadequately fulfilling caring work according to their own ethical standards might also lead paramedics to develop moral distress, a phenomenon often occurring when healthcare professionals feel powerless to take the ethically correct action [
17,
18].
Other commonly reported job demands among paramedics are environmental, sociocultural and organisational; critical incidents causing psychological distress [
19]; traumatic events concerning patient care [
20]; the threat of violence from patients and bystanders [
21]; and the risks related to alarm-vehicle driving [
22], uncertain working environments [
8] and physical injuries [
23,
24]. Meanwhile, individual performance pressure [
25], conflicts of an ethical nature [
26] and social pressures [
7], as well as continuously occurring emotional patient encounters [
27], seem to be inherent phenomena within the EMS profession. Hence, paramedics’ own emotions are an inherent part of caring work [
25]. This—combined with an often underlying organisational culture of stigmatising professionals’ own mental well-being—can lower paramedics’ thresholds to ask for support [
28]. Accumulations of such aforementioned stress factors have shown correlations with an increased risk for paramedics’ burnout and fatigue and even the changing profession [
5,
27,
29,
30], as well as decreased performance and a higher risk for patient safety [
31].
Choosing to take a descriptive view without expectations of providing explanatory perspectives, as we considered the novelty of Finnish paramedics as research population, we set out to investigate how paramedics view their work. With an underlying interest in how it relates to their work well-being, we considered the use of the job demands and resources (JD-R) model as adequate for sorting the data [
32,
33]. Developed by Demerouti and Bakker, the JD-R model is a validated theoretical model showing a pathway between job demands and resources to work-related stress, burnout and compassion fatigue [
32] and, inversely, positive and fulfilling engagement in work [
34,
35]. Although the JD-R model is mainly used in quantitative approaches, it has also been utilised for qualitative applications in attempts to explore healthcare workers’ stress more deeply [
33,
36,
37].
The current study aimed to describe paramedic professionals’ work and their own perceptions of job-related demands and resources, patient care and their relations within their professional community. This was accomplished utilising two research questions: 1) What job demands do Finnish paramedics perceive as being related to work in EMS? 2) What job resources do Finnish paramedics perceive as being related to work in EMS?
Discussion
Our aim was to describe what Finnish paramedic professionals perceive as job-related demands and resources in their EMS work. Our findings identified both paramedics’ own emotional responses and the environmental and organisational factors, some potentially anchored in deep cultural values around managing and performing. Although previous research by Lawn et al. [
7] and Afshari et al. [
8] supports our findings of paramedics’ job demands, we also identified novel themes. Cultural values were commonly related to Finnish paramedics’ strong sense of role expectations and a pressure to continuously perform well, which was coupled with recurring implications of prevalent strong ‘macho’ cultural values within the organisations; these values had potentially negative effects on individuals’ threshold to address mental well-being issues.
One of the traditionally rooted aspects of paramedic work is having wide clinical knowledge and emergency care skill sets with expectations to perform under various demanding situations [
8], often during 12- to 24-h long shifts, when both mental and cognitive capabilities might vary considerably. Paramedics further need to have the ability to function under diverse circumstances while still being adaptable to changes, both regarding the environments they work in and their patients’ acutely deteriorating conditions, but also in handling their own—as well as others—emotional responses. Henckes and Nurok (2015) note that emotion work in EMS is multifaceted, often involving paramedics having to continuously adjust their own emotions to that of their partners, while having limited time for necessary reflection or rectification [
25]. This expectation was also noted in our results, with the participants’ expressions relating to the emotional dynamics between job partners, which could sometimes be perceived as burdensome, especially during long 24 h shifts, if mutual trust or an ethical value base was not present.
As noted in our findings and further supported by previous work by Lawn et al. (2020), paramedics’ job demands can be both externally formed, such as how their work is organised and supported or more private in nature, which can involve facing adversities or lack of control over their work [
7]. Our study mirrored this, with findings suggesting Finnish paramedics’ performance expectations seemingly are derived from a motivation to perform to high standards that are partly catalysed by the previously mentioned organisational and cultural norms. The Finnish paramedics expressed having an adequately high level of competency in relation to the work demands, and they also felt that this empowered a sense of control over their clinical work, giving them the ability to handle most situations. Such expectations of performance, however, may form a dual-edged sword; for some, this may catalyse a personal drive towards developing their competencies further and moving towards professional self-actualisation [
50], which is a positive outcome also presented in our research. Meanwhile, others may consider such expectations as adding stress to their work [
8]. This manifested, among others, in the form of annual formalised competency tests, which some attributed to increasing their work-related stress, as did feelings of having to live up to the role of a highly educated paramedic. Such job cultural expectations also pertained to the paramedics’ sense of having to manage a continuing high mental workload, potentially accumulated during 12- or 24-h shift with concurrent calls.
Furthermore, EMS work involves inherent environmental hazards and risks that need to be managed, some on an almost daily basis. Notable environmental or assignment-related hazards are an increased prevalence of violence and threats towards paramedics [
8], which has reached a point where it might be expected and even normalised [
51]. Other risks we discovered relate to road scene safety and increased risks during alarm-vehicle driving [
22]. This potential for risk situations is clearly categorised as demands adding to paramedics’ daily job stress and mental workloads.
Paramedic work inherently involves job-related resources, that is, aspects that are functional for work achievement, motivating and stimulating personal development or reducing job demands [
34] and, hence, leading to higher job engagement. These resources include strong peer communities of practice [
25], a sense of autonomy and reported high levels of social prestige of the EMS profession [
52]. Such sociocultural and organisational aspects have been reported as mitigating negative stress outcomes in acute caring work [
25] and, as presented in a systematic review by Yu et al. (2019), are important factors in the formation of resilience among acute healthcare personnel [
53]. Notably, EMS seems to form a respected community of practice, connecting to a strong sense of belonging among paramedics [
25]. This might stem from spending such long shifts, often between 12 to 24 h, together. As also noted in our findings, a strong sense of professional identity seemed to shape personal pride in being a paramedic [
54]. These may well function as job-related resources towards thriving at work, especially if combined with a high degree of support and psychological safety within the job community [
55]. These findings are also mirrored in our results, supporting the notion that many participants felt an almost familial bond with their paramedic peers and that they could openly discuss their own emotions and uncertainties within their community.
A concurrent aspect also evident in our findings was paramedics’ expressions of having to bear an emotional burden stemming from encounters with patients and relatives. Based on paramedics’ own perceptions, such emotions traditionally seem to be commonly related to experiences involving acutely sick children and lonely elderly. Although these clearly differ from each other, a potentially common denominator between such experiences might be paramedics’ sense of helplessness; paediatric patients are generally rare in EMS and often elicit stronger emotions in healthcare personnel [
56], here buoyed by feelings of fear and, perhaps, uncertainty [
57]. Meanwhile, daily occurring EMS assignments involving patients with complex pathologies or social distress, such as elderly loneliness, isolation, long-term substance abuse or chronic conditions, are not easily managed and treated before arriving at the hospital. As noted earlier, although the competencies that paramedics had built during their training were deemed adequate and relevant for the actual practical work, which many also expressed provided a sense of safety in their clinical work, paramedics are inherently more specialised in treating emergency conditions and trauma care and, as such, are not always equipped to handle such aforementioned situations, which often fall outside their range of specialties [
11]. As our findings suggest, this might connect to a sense of inadequacy, mainly from not being able to help as much as one would want [
7]. This has the potential to manifest as paramedics’ general frustration over ‘nonrelevant’ or even ‘nonsensical’ assignments, especially as such assignments may easily be a majority during 12- or 24-h shift, where chances to mentally recuperate between them might be low. Mausz et al. (2022) have also noted this form of cognitive dissonance as stemming from the discrepancy in paramedics’ expected role and what turns into an espoused paramedic identity, manifesting in such frustrations of nonurgent calls and frequent ‘system abusers’ [
58]. Similar phenomena have been noted by Lazarsfeld-Jensen (2014), who investigate how storytelling and rescue myths imbued on young graduate paramedics might enforce an image of paramedics as rescuers or ‘masters of chaotic spaces’, working mostly as live-savers and ‘requiring critical events as proving grounds’ [
11].
Although there is ample evidence of paramedics’ occupational stress factors and their subsequent effects, there is a paucity of specifically qualitative literature aimed at exploring paramedics’ individual perceptions of what they identify as occupational demands and resources, something that is also noted in a systematic review by Lawn et al. [
7]. Such a bilateral perspective is also relevant for identifying the underlying aspects related to paramedics’ stress levels and understanding their work engagement and individual resilience development while also considering the need to develop organisational psychosocial safety and educational support.
Our aforementioned findings on expectations and managing form what could be described as the bane of EMS: paramedics seem to form a community of resilient professionals [
59], independently functioning frontline emergency clinicians who are expected to hold large amounts of knowledge and skills but who also are expected to carry the emotional burden of their work on their own shoulders. The undercurrents of a prevailing culture of hardiness, described also in our findings as a ‘macho culture’, were evident within the Finnish paramedic communities. This manifested as a lack of proper peer and manager support, lacking psychological safety, high thresholds to activate defusing systems and paramedics’ sense of general inequality in relation to management, lacking the feedback or possibilities for career advancement. As noted by Lawn et al. (2020), asking for support within a culture of hardiness might be seen as a sign of weakness or, worse, not belonging [
7]. Although there are signs that such ‘old-time cultures’ are slowly subsiding and being replaced by a more open and psychologically aware mentality, these findings are not geographically unique because they have been noted in EMS cultures in previous research [
28].
An often-iterated presumption is that strong mental resources are—or should be—the natural requirements of paramedics and first responders. In other words, they should be resilient. Of course, this implies that a focus on individual resilience is relevant in the first place, something that the inherently unpredictable work in EMS might well justify. However, the notion of having this ‘right stuff’ from the start is simply not feasible. There is certainly an advantage, especially at the early stage of one’s career, in having adopted good and functional coping mechanisms to handle the unexpected job-related stressors inherent in EMS work [
19]. However, paramedic education needs to focus on identifying and forming such initial building blocks while the work culture and environment then furthers to support them, aiming to strengthen these internal resources and finally enabling the growth of paramedics’ necessary resilience [
53]. To further understand the connection between paramedics’ work stress and mental well-being and to facilitate a discussion on how paramedics’ resilience could be constructed and strengthened, future research could look more specifically at the role of job demands, control and support models [
60].
Methodological considerations
The use of Job Demands and Resource model was based on strong validation from within the occupational health literature [
32,
33]. This also brings a methodological limitation, as a model is always merely a codified representation of reality and other models could also have been equally suitable. However, we did find that for the scope of this particular study aim, the JD-R model was sufficiently relevant in adding value. The use of the JD-R model from a qualitative perspective further brings challenges, as the model is mainly used for quantitative use.
Our research data represented both a widely dispersed and presumably heterogeneous population and, similarly, a more narrowly focused population consisting of emergency medical care master’s degree students. Although we agree that using students as participants does raise relevant questions regarding power imbalance, as the essays were written prior and independent of the study, as part of a coursework and later, due to their range in content, used for research purposes (with consent), the discrepancy between role as ‘student’ and ‘participant’ becomes more solved. This also gave us the opportunity for an overview on a more general level (data set A) while also examining a smaller sample that presumably represented individuals with internal motivations to develop and broaden their competencies by attaining a higher degree (data set B). A mixed sampling of participants allowed for a balance between similarities and differences in participant demographics and increased the dispersion of their geographical location. We are, meanwhile, mindful of factors which might shape the reporting of participants’ experiences from both data sets, such as, among others, time of day, previous traumatic experiences, recurring memories and/or overall experience of the field as well as ability to verbalize own perceptions and reflections. This was noted in high variability of response lengths in data set A.
Although purposeful sampling aims to select individuals who are especially knowledgeable about a phenomenon of interest [
61], targeted snowball sampling through social media is a recognised and viable way to reach a wider public, even though there are known challenges relating to potential bias [
62]. Use of web-based survey for qualitative data collection is not ideal compared to focus groups or interviews, which would probably yield more deep and rich qualitative data. However, considering the novel nature of the research field, this method allowed us to cast a wide net, enabling us to capture surface elements which can be explored later in more depth. As the study aim was rather broad, we found using a larger participant count, increased the diversity of experiences from a larger sample [
63]. We further agree that, as a qualitative approach, both data sets were exceptionally large and quality was partly shallow (mainly data set A). Although thematic saturation was not addressed explicitly in the analysis, we felt the combination of the distinct data sets, with breadth and depth, impacted the quality of the dialog and thus overall information power [
63]. Patient or Public Involvement (PPI) could also potentially yield rich in-depth data. PPI was, however, not utilized in this study due to practical and economic reasons mostly concerning recruitment and timing. However, PPI use in further studies of the subject would certainly add value and would be highly encouraged.
We chose to translate the data from the original languages (Finnish or Swedish) to English. Being aware that language translation always brings the risk of potentially losing nuances or latent implications inherent within the original language used [
64], we considered that a common language would still further a more coherent analysis phase. We were also mindful that because the translation was done by the first author, who was familiar with the paramedic and EMS context, certain themes and implications pertaining specifically to the profession would perhaps more easily be comprehended.
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