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. (Lawn et al., 2020) and Afshari et al. (Afshari et al., 2021) 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 and expectations to perform under various demanding situations (Afshari et al., 2021). The premise is that paramedics 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 (Henckes & Nurok, 2015). 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 if mutual trust or an ethical value base was not present.
As also 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 (Lawn et al., 2020). 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 (Wallin, Werkander Harstäde, Bremer, & Hörberg, 2021), which is a positive outcome also presented in our research. Meanwhile, others may consider such expectations as adding stress to their work (Afshari et al., 2021). 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.
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 (Afshari et al., 2021), which has reached a point where it might be expected and even normalised (Mausz, Johnston, & Donnelly, 2021). Other risks we discovered relate to road scene safety and increased risks during alarm-vehicle driving (Koski & Sumanen). This potential for risk situations is clearly categorised as demands adding to paramedics’ daily job stress and mental workloads.
Notably, EMS seems to form a respected community of practice, here connecting to a strong sense of belonging among paramedics (Henckes & Nurok, 2015). As also noted in our findings, a strong sense of professional identity seemed to shape personal pride in being a paramedic (Johnston & Bilton, 2020). 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 (Kleine, Rudolph, & Zacher, 2019). 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 (Oulasvirta, Harve-Rytsälä, Lääperi, Kuisma, & Salmi, 2021), here buoyed by feelings of fear and, perhaps, uncertainty (Öberg, Vicente, & Wahlberg). Meanwhile, daily 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 (Lazarsfeld-Jensen, 2014). 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 (Lawn et al., 2020). This has the potential to manifest as paramedics’ general frustration over ‘nonrelevant’ or even ‘nonsensical’ assignments. 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’ (Mausz, Donnelly, Moll, Harms, & McConnell, 2022). 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’ (Lazarsfeld-Jensen, 2014).
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 (Clompus & Albarran, 2016), 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 (Lawn et al., 2020). 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 (Mackinnon et al., 2020).
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 (Loef et al., 2021). 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 (Yu et al., 2019). 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 (Portoghese et al., 2020).
We chose to take a descriptive view without any expectations of providing explanatory perspectives. As such, the study purposefully takes a strong ‘what’-stance, which differs from a ‘how’ or ‘in what ways’, as we considered the novelty of Finnish paramedics as research population. Because we set out to investigate how these paramedics view their work, here with an underlying interest in how it relates to their work well-being, we considered the use of the job demands and resources model as adequate for sorting the data (Castner, 2019; Singh et al., 2020).
The use of Job Demands and Resource model was based on strong validation from within the occupational health literature (Castner, 2019; Singh et al., 2020). This naturally 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 (Palinkas et al., 2015), 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 (Leighton, Kardong-Edgren, Schneidereith, & Foisy-Doll, 2021). We further 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 (van Nes, Abma, Jonsson, & Deeg, 2010), 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.
We addressed the question of overall study trustworthiness through various means based on the frameworks noted by Nowell et al. (2017) and following the steps of reflexive thematic analysis, established by Braun and Clarke (Braun & Clarke, 2006). For study credibility, the first author engaged in the material for prolonged times, systematically reviewing the data and with time intervals between analyses to allow for the reframing of previous observations (Nowell et al., 2017). We also applied researcher triangulation because all authors participated in the analysis phase. Because of the sampling method (web-based survey and student essays), member checking to go over interpretation with the participants was not possible. We describe the process in detail to better enhance dependability, while transferability or generalisability of the study was addressed through descriptions of the context, data collection and participant demographics, as far as possible (Nowell et al., 2017).