2. Organisational Challenges

2.1. Team Relationships

Team Relationships

“All of the participants mentioned feeling overlooked, misunderstood and marginalized. When specifically discussing the public perception, participants described feeling invisible.”

^[13][18]

These perceptions from other EFRs, as well as their effects on dispatch staff, seem to erode working relations, creating conflicts and contributing to job-related stress. Furthermore, although team-building exercises were carried out within the organisation, participants felt that these training sessions did not address what was really important and relevant for their context. Subsequently, some argued that these exercises amplified their feelings of being devalued, as they felt that their time was ill-spent. This indicates that when organisations aim to develop team-building programmes, these programmes need to address the specificities of the EFR profession. Issues in co-worker relations, and in particular, relations established with leadership representatives have also been reported elsewhere, Dropkin et al. ^[14][19] following interviews with a sample of emergency medical service workers (EMS) and their supervisors. In this case, lack of trust between leaders and EMSs, as well as lack of consideration from leadership in relation to the safety needs of EMSs were noted as main organisational challenges. Moreover, organisational policies for employing new EMSs contributed to an increase in job-related stress, as an initial screening process for physical fitness was lacking. This was a main concern for EMSs as they were also unable to choose a shift partner and were thus left with carrying out heavy lifting during patient transport on their own.

2.2. Organisational Resources and Salaries

Organisational Resources and Salaries

From the qualitative data assessed Coxon et al., Dropkin et al. ^[13][14][18,19], insufficient pay and limited organisational resources have also been reported as contributors to stress. For example, as noted by one dispatch participant ^[13][18], the lack of availability of ambulances while taking an emergency call creates significant pressure and stress for the dispatch workers.

“In dispatch, the main stressors are not having the resources, in terms of ambulances for emergencies. (Jane, female, 13½ years in role).”

^[13][14][18,19]

Similarly, other similar investigations Dropkin et al. ^[14][19] found that limited resources available for staff training and equipment are acknowledged by supervisors and EFR employees alike, yet solutions are lacking. EMS further acknowledged that ergonomic training is relevant for preventing injuries, while supervisors note that resources for this type of training are scarce.

“Supervisors also noted that workers needed more training on waiting for help (either from another EMS team or a supervisor) and not rushing on the last call in order to go home. However, they noted there was no scheduled time for additional training on appropriate and safe work practices.”

^[13][14][18,19]

Participants in qualitative studies ^[13][14][18,19] reported underpay as a main issue related to job dissatisfaction. Moreover, underpay forced many EMSs to take on second jobs. In return, this impacted on their ability to fully rest after shifts, especially following night shifts.

“Initially, when asking Darren what his routine was after finishing work, he confessed to not really having a routine. As Darren explained, he often returns to work not feeling refreshed, and he now does not experience the same enjoyment in his role as he used to.”

^[13][14][18,19]

“Low pay, work shifts, and second jobs were related according to workers. Low wages led to second jobs, but most had no choice because of their salaries.”

^[13][14][18,19]

2.3. Work Schedules and Shifts

Work Schedules and Shifts

Several studies ^{[13][14][15][16]}[18,19,20,21] identified shifts and work schedules as main challenges for EFRs. In this case, night shifts, workload, poor sleep-wake patterns, understaffing, as well as working second jobs were found to decrease job satisfaction and increase the likelihood of burnout and fatigue. These issues were significantly amplified for participants who also had family responsibilities. As noted by participants in these studies, poor dietary habits were common, as limited breaks and busy working schedules do not allow for proper meals during shifts. Additionally, working second jobs impeded EFRs to rest properly between shifts, with family life further adding to fatigue and exhaustion. As reported by this research ^[13][18], while EFRs may take shift breaks, especially after a stressful situation, when they get back on the clock, they often find themselves in a completely different crisis situation. Quickly adapting to the new scene has been reported as an additional stressor. With heretic shift schedules, second jobs, and the stress of work, many participants found it hard to relax after their shifts and have an adequate work–life balance. Concomitantly, others noted that family stress further added to their feelings of fatigue.

3. Professional Challenges

Specific professional challenges related to emergency services were reported by all studies included for review ^{[13][14][15][16][17]}[18,19,20,21,22]. These challenges included the need for specific training and equipment, environmental risks, working with heavy loads, as well as balancing professional and social lives. Considering that the samples in the studies included for review consisted in majority of emergency medical service workers, it can be argued that the identified professional challenges may apply only to this profession. Hence, additional challenges may be present in other EFR professions. Environment risks identified derive from weather conditions, but also from the specifics of the emergency where EFRs must provide assistance. For example, emergency response workers are often exposed to bushfires while carrying out their duties as part of rescue and rebuild missions Eriksen ^[15][20]. Weather conditions were reported as physical exposure factors that can result in physical injuries Dropkin et al. ^[14][19]. The availability of protective equipment seemed to mitigate these risks Coxon et al. ^[13][18]. Rural ambulance staff perceived that they are exposed to harm, especially when lacking protective equipment against fires Pyper and Paterson ^[16][21].

“These responses included being located in a ‘rural area’, being exposed to ‘hot weather’ and being ‘not adequately prepared for heat waves/bushfire crises.”

^[16][21]

Other physical risks identified include musculoskeletal injuries that are attributed to carrying heavy loads during patient transportation or while carrying heavy equipment ^[14][19].

“Once I have an injury, just one wrong move with a patient or when carrying equipment will flare me up. I can lose three months of work.” Most supervisors reported that weight and number of pieces of equipment that EMS staff and their partners carried and handled, combined with icy, wet weather were ‘headaches’.”

^[14][19]

Some amplifying effects were observed, as being in physical pain while on the job further amplifies psychological stress in this group ^[14][19]. Consequently, these aspects denote that EFRs may be exposed to further decline in psychological wellbeing when sustaining a physical injury. At the other end of the spectrum, working in emergency services in rural areas may be particularly challenging, as in some cases EFRs may need to work alone, while at the same time depend on the response time of metropolitan services ^[17][22].

4. Community

In two of the studies identified Eriksen, Pyper and Pateron ^[15][17][20,22], the community served by EFRs acted both as a motivator and social support factor, but also as an additional stressor. In supporting populations through disaster recovery, workers in disaster recovery were noted to develop social connections with people from the affected community, which further contributed to the development of a sense of collectiveness and faith in humanity ^[15][20].

“Faith driven by group-identity connects to collectively created mental, spiritual and physical spaces and practices where it is ‘safe’ to confide, reflect, debate, grow and heal through interaction with people who share a common purpose, belief or relational support.”

^[15][20]

These effects were noted to buffer out stress from team tensions, as well as stress emerging from risks of exposure. Concomitantly, within these social connexions, disaster recovery workers felt a sense of purpose that allowed them to withstand physical and mental stress. Despite these observations, rigid hierarchical structures, power dynamics, and imbalances can create additional psychological stressors for recovery workers ^[15][20]. These findings are not singular, as dispatch workers reported feeling personal and professional satisfaction when they were able to provide life-saving support to people but felt devalued by other EFRs ^[13][18]. A sense of purpose and professional pride was also reported by participants, which further contributed to decreasing work-related stress. However, results from research using small regional EFR samples ^[17][22] indicates that working in small communities can be both a factor that improves professional satisfaction, as well as an additional work-related stressor.

“While several respondents stated that treating personally known patients is a source of significant stress, it was also identified that this can be rewarding. This is largely due to a ‘higher expectation to perform well’ and because ‘many (patients) are known friends or family’. However, it was also reported that ‘treating personally known patients who are not in a serious condition is easier and quite rewarding’.”

^[16][21]

In this case, interviews with regional ambulance staff workers showed that by being able to offer support to people that they know personally, participants felt a sense of professional and personal satisfaction. Nonetheless, when treating seriously ill patients that are known personally by ambulance staff, stress is significantly increased.