New development: A ‘journey of personal and professional emotions’—emergency ambulance professionals during Covid-19

IMPACT

This article explores the consequences of emotional labour on UK NHS ambulance staff and their response to the Covid-19 pandemic. It highlights the challenges faced by ambulance crews while dealing with their emotional labour within the context of organizational settings. Research findings also explain the importance of emergency responders’ psychosocial wellbeing. The article has clear relevance as to how frontline staff manage their emotional labour in other emergency service settings, such as the police and fire and rescue services.

ABSTRACT

Managing emotions are essential aspect of many jobs, and frontline healthcare workers have to manage and control their emotions while caring for critically ill patients and working in an emotionally-charged dynamic environment; this was particularly the case during Covid-19. Ambulance workers are an important group in this respect but they are currently under-researched. Evidence behind this article comes from data collected from an NHS ambulance trust in England. One of the key contributions of this article is to highlight how frontline ambulance professionals manage their emotional labour while working within the stipulations of organizational constraints.

KEYWORDS:

• Ambulance personnel
• Covid-19
• emergency services
• emotional labour
• NHS ambulance trust
• organizational factors
• resilience

Introduction

Emotional labour refers to managing one’s own emotions as required by one’s profession (Hochschild, 1983). Street-level bureaucrats (such as nurses, social workers and medical doctors) routinely deal with emotional situations that require them to supress their emotions to match organizational and job expectations, while having significant discretion in conduct of their jobs (Guy & Newman, 2004; Lipsky, 2010). This may help to make the public feel good or bad, depending on the situation (Mastracci et al., 2006). This article contributes to the growing debate on how frontline ambulance professionals deal with their own emotional labour, in the context of organizational factors and attributes, while carrying out their life-saving public duties. In addition, it adds to the wider debate about how emotions are tackled by professionals used to experiencing strong emotions during a crisis like the Covid-19 pandemic.

Emotional labour in emergency ambulance setting

Public servants and street-level bureaucrats, such as emergency ambulance professionals, namely, frontline paramedics and technicians, emergency co-ordination centre staff (call handlers/dispatchers) and operational managers, are the first point of contact for emergency (999/911 etc.) calls. They routinely engage with the general public in a series of communications, while discharging their labour in unpredictable and emotional pre-hospital care settings. Ambulance professionals are expected to provide assurance to patients and to treat them safely in the scope of organizational protocols, while meeting stringent response time targets (Wankhade et al., 2018; 2020). The work of emergency ambulance professionals, in which ‘emotions’ are part of the job, may be undervalued since such emotional labour is simply ‘expected of them’ (Henderson & Borry, 2020, p. 2). This often entails remaining calm and hiding their own true feelings in a ‘dynamic’ (sometimes both intense and dangerous) work environment (Furness et al., 2020; Lawn et al., 2020; Maguire et al., 2014; Sterud et al., 2011). However, a robust evidence-base on the impact of organizational factors and characteristics on managing emotional labour by emergency ambulance professionals is still evolving.

The arguments for the intensity of the ambulance work and its perverse impact on professionals’ physical and psychosocial wellbeing have been well rehearsed in the literature (Granter et al., 2019; Wankhade, 2016). Notwithstanding the empirical evidence linking the emotional nature of ambulance provision to stress, post-traumatic stress disorder (PTSD), burnout including bullying and harassment, no real accountability exists in terms of who is responsible for such negative outcomes (Furness et al., 2020; Kline & Lewis, 2018). Similarly, the impact of a lack of adequate funding to meet the ever-increasing demand for emergency ambulances, dealing with staff shortages and sickness absence (Buchan et al., 2019; NAO, 2017), has been further exacerbated by over-stretched, over-stressed and emotionally-challenged frontline ambulance staff.

Insights from research

Evidence gathered from interviews conducted with a range of staff in an English National Health Service (NHS) ambulance service, who also shared their experiences of dealing with their emotions while working through the Covid-19 pandemic, reveals a complicated situation. A senior operations manager summed their experience as ‘A journey of personal and professional emotions’.

Ambulance professionals are often portrayed as ‘macho’ and ‘heroes’ in the media and this carries in public minds (Tangherlini, 2000). However, the emotional trauma and stress at the peak of the pandemic was far too much even for experienced staff and many respondents felt that their personal resilience was ‘tested to the maximum’. For example a senior manager reported—‘Personally I am feeling fatigued and tired but for me, it’s the ‘adrenaline’ which is getting me through this emotional crisis’.

Literature highlights the impact of organizational structures and procedures on emotional labour, especially in healthcare (Miranda & Godwin, 2018). Ambulance services are witnessing a steady annual increase in emergency call outs. Ambulance professionals follow strict protocols to make triage decisions and decisions about clinical pathways for treating patients. The pandemic required a quick response and changes to triage and treatment protocols from ambulance professionals without endangering patient safety in a service which has been historically characterized as ‘risk averse’. Many respondents felt the ‘micro-trauma’ of not being able to do more to help and support the patients. Frontline staff shared a range of emotions—‘deflated’, ‘beaten’ ‘sorrow’, ‘helpless’—while carrying their life-saving duties in a dynamic and fluid pandemic situation. One frontline paramedic said: ‘The uncertainty of the patient presenting “Covid-19” symptoms challenged you clinically; and you felt frustrated that you couldn’t do more for the patient’.

The role of the organizational ‘relationships’ in emotional labour has also been discussed (Henderson & Borry, 2020). Frontline ambulance crews and emergency operations centre staff (call handlers and dispatchers) sometimes work on their own (as solo responders), but quite often they work in pairs or in teams and develop routines to cope with the physical and emotional demands of shift work. Depending on the levels of mutual trust and co-operation in these relationships, emotional labour can be high or low. The pandemic tested these relationships further. Interestingly, most of our respondents spoke with pride and satisfaction of ‘being in it together’, which helped them to cope up and manage their emotions. For example, an emergency dispatcher responded: ‘Your work mates became your new family and your support system … We took care of each other’.

However, cases of work-related harassment, bullying, stress or burnout are also on the rise in ambulance service (King’s Fund, 2015; Kline & Lewis, 2018; Wankhade, 2016), impacting on the emotional labour of these street-level bureaucrats and this issue requires further investigation and analysis. In particular, we need to look at instances of street-level bureaucrats stepping into each other’s shoes by getting deployed in areas other than the ones they trained for, in an effort to assist with the pandemic relief efforts.

Covid-19 added to the trauma caused by efficiency-maximization

New Public Management (NPM) style reforms, implemented in several OECD countries over the past three decades, have been promoted as progressive, transparent, cost-effective, over-due and equitable (Groot & Budding, 2008; Hughes, 1992) by allowing street-level bureaucrats discretionary power to make decisions or establish routines towards equitable use of resources in the interests of public good (Lipsky, 2010). Yet research evidence paints a very different picture of emergency ambulance professionals as publicly funded street-level bureaucrats. Not only do they exhibit limited discretionary power(s) while conforming to organizational norms but, worryingly, they also display extremely high levels of stress and burnout due to the very emotional nature of their job: causing ‘moral injury’ (Greenberg et al., 2020) and psychosocial harm, in addition to physical injuries (Mildenhall, 2019). It is important to highlight the significance and role of organizational factors, and to add to the limited but growing body of work on the impact and implications of the work-related stress among the emergency ambulance professionals while managing their emotions (Guy et al., 2008; Nelson et al., 2020).

Austerity-driven reforms have allowed managers to use increased bureaucracy and red tape (Lipsky, 2010; Pollitt & Bouckaert, 2017) to reduce the discretionary power of ambulance professionals (Wankhade et al., 2018): a trend also witnessed in other emergency services such as the police (Farr-Wharton et al., 2021). The pandemic has further exposed these street-level bureaucrats to additional trauma, burnout while tackling Covid-19 in addition to dealing with personal protection equipment (PPE) shortages, sickness or death of colleagues, exacerbated by feeling isolated and not being able to share (Cosslett, 2020).

Emergency ambulance professionals go through a range of emotional situations while discharging their duties, in often unstable and dynamic situations. The Covid-19 pandemic intensified the pressure for ambulance responders to manage their emotional labour because they were exposed to further risks and physical and psychosocial harm (College of Paramedics, 2020). A resilient and healthy workforce is central in mitigating the negative outcomes of some of the organizational factors involved in the work of first responders. A compassionate leadership approach, accompanied by managerial support and a nurturing organizational culture, can help staff to deal with emotional trauma and stress.

Concluding remarks

Several research implications follow from this article. The negative consequences of emotional labour, not only on the physical and psychosocial wellbeing of ambulance professionals, but also on citizens, patients, and users of public services, deserve much more attention. More empirical studies in wider emergency services settings (such as police or fire and rescue), will help to bring much needed evidence to appreciate and analyse the role of organizational factors and characteristics. This will help to improve scholarly and practitioner understanding of the way street-level bureaucrats manage their emotional labour in specific organizational contexts. Such a research agenda will contribute towards an important but currently under-researched, theme in the public administration discourse. Suppressing emotions, or not managing them well, can also lead to depression, anxiety, burnout and decreased job performance, and may contribute further to higher rates of sickness absence and financial burden to the organization (Wankhade, 2016). If not managed properly, such stress can also affect personal and home life. This is highly relevant within the context of the ambulance services, who routinely work under stressful, emotional and a dynamic environment.