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There is a growing academic interest in the examination and exploration of work intensification in a wide range of healthcare settings. The purpose of this paper is to explore the differing staff perceptions in emergency ambulance services in the UK. It provides evidence on the challenges for the paramedic professionalisation agenda and managing operational demands and work intensity in emotionally challenging circumstances, with significant implications for patient safety.

Drawing on the evidence from an empirical study in a large National Health Service ambulance trust in England, this paper examines the challenges and differing staff perceptions of the changing scope and practice of ambulance personnel in the UK. Amidst the progress on the professionalisation of the paramedic agenda, individual trusts are facing challenges in form of staff attitudes towards meeting performance targets, coupled with rising demand, fear of loss of contracts and private competition.

Research findings highlight differing perceptions from various sub-cultural groups and lack of clarity over the core values which are reinforced by cultural and management differences. Need for greater management to explore the relationship between high sickness levels and implications for patient safety including the need for policy and research attention follows from this study. The implications of work intensity on gender equality within the ambulance settings are also discussed.

Ambulance services around the world are witnessing a strain on their operational budgets with increasing demand for their services. Study evidence support inconclusive evidence for patent safety despite the growing specialist paramedic roles. Organisational implications of high staff sickness rates have been largely overlooked in the management literature. This study makes an original contribution while building upon the earlier conceptions of work intensification.

The study findings have significant implications for the ambulance services for better understanding of the staff perceptions on work intensity and implications for patient safety, high sickness absence rates amidst increasing ambulance demand. Study findings will help prepare the organisational policies and design appropriate response.

Societal understanding about the organisational implications of the work intensity in an important emergency response service will encourage further debate and discussion.

This study makes an original contribution by providing insights into the intra-organisational dynamics in an unusual organisational setting of the emergency ambulance services. Study findings have implications for further research inquiry into staff illness, patient safety and gender issues in ambulance services. Evidence cited in the paper has further relevance to ambulance services globally.

In North America, delegated practice “medical direction” models are often used as a proxy for clinical quality and safety in paramedic services. Other developed countries favor a combination of professional regulatory boards and clinical governance frameworks that feature paramedics taking lead clinician roles. The purpose of this paper is to bring together the evidence for medical direction and clinical governance in paramedic services through the prism of paramedic self-regulation.

This narrative synthesis critically examines the long-established North American Emergency Medical Services medical direction model and makes some comparisons with the UK inspired clinical governance approaches that are used to monitor and manage the quality and safety in several other Anglo-American paramedic services. The databases searched were CINAHL and Medline, with Google Scholar used to capture further publications.

Synthesis of the peer-reviewed literature found little high quality evidence supporting the effectiveness of medical direction. The literature on clinical governance within paramedic services described a systems approach with shared responsibility for quality and safety. Contemporary paramedic clinical leadership papers in developed countries focus on paramedic professionalization and the self-regulation of paramedics.

The lack of strong evidence supporting medical direction of the paramedic profession in developed countries challenges the North American model of paramedics practicing as a companion profession to medicine under delegated practice model. This model is inconsistent with the international vision of paramedicine as an autonomous, self-regulated health profession.

Current statistics highlight the increasing prevalence of homelessness in Australia, however, there is scant research regarding empathy and homelessness in the paramedic literature. Research in other areas of healthcare demonstrates that interaction with the homeless can positively impact empathetic attitudes and also highlights the opportunity to examine if these results are consistent or generalisable to the Australian paramedic profession. Therefore, the aim of our study was to explore paramedic students' empathetic attitudes towards homelessness.

A sequential mixed method design study was undertaken using a repeated measures and focus group approach. Paramedic students participated in clinical experience, involving interactions with the homeless. This entailed participating in at least four shifts (11 pm – 5 am) where students gained experience at the Salvation Army Health Café or with the Youth Street Teams in Melbourne, Australia. Empathy levels of the paramedic students toward homelessness, both pre- and post- were measured using the Medical Condition Regard Scale (MCRS) and the Health Professionals' Attitudes Toward the Homeless Inventory (HPATHI). A focus group with student participants was also conducted to obtain further detailed information about their perceptions of the experience.

A total of 20 students participated (100% response rate). Statistically significant (p < 0.05) increases were observed on the MCRS pre- to post- data with total mean scores of 48.35 (SD ± 8.33) and 51.65 (SD ± 5.56), respectively. On the HPATHI a statistically significant (p < 0.0001) increase in Personal Advocacy was observed. Eight of these students took part in a subsequent focus group. Following thematic analysis of the focus group, a number of common themes were identified that included: communication, empathy and rapport, and a change in perception and attitude.

The results of this pilot study demonstrate that through participation in a project involving experience interacting with the homeless population, paramedic students showed a greater level of empathy towards the homeless. Increases in empathetic regard, social advocacy and personal advocacy were also found.

Review of major policy paper in relation to the ambulance service [in England] efficiency and productivity with reference to observed “unacceptable variation”.

Critical review of ambulance service/EMS policy approach in England.

Lord Carter’s review describes failings in performance of UK ambulance service/EMS. However, the identified failings are essentially a repetition of many almost identical similar findings. There is a tendency of policy in respect of the ambulance service in England, as exemplified by Lord Carter’s report to consider analysis of the problem a more significant task that actually addressing the shortcoming defined.

This viewpoint comment piece is produced as a viewpoint with all the attendant limitations implied in this approach. However, it has been produced from an informed position.

Challenge to current UK ambulance policy. Previous repetitious finding need to be addressed definitively.

The efficiency of UK ambulance services/EMS is seriously impaired, and indeed these findings have been acknowledge previously. However, little by way of active remediation has been attempted. The current approach as exemplified in Lord Carter's recent review appears to ensure that analysis of the long- standing problems that exist is sufficient and possible preferable to active remediation and improvement.

No previous critical review of this type has been attempted (as it would be career-limiting).

NHS 111 is a non-emergency telephone triage service that provides immediate access to urgent care 24 h a day. This study explored the recruitment, retention and development of one integrated urgent care (IUC) workforce in England, specifically the NHS 111 service and Clinical Hub.

An online survey was distributed to the NHS 111 and Clinical Hub workforce. The data from 48 respondents were summarised and analysed thematically.

The survey respondents held a variety of clinical and non-clinical roles within NHS 111 and the Clinical Hub. The findings indicate that the IUC workforce is motivated to care for their patients and utilise a range of communication and cognitive skills to undertake their telephone triage roles. In total, 67% of respondents indicated that their work was stressful, particularly the volume and intensity of calls. Although the initial training prepared the majority of respondents for their current roles (73%), access to continuing professional development (CPD) varied across the workforce with only 40% being aware of the opportunities available. A total of 81% of respondents stated that their shifts were regularly understaffed which indicates that the retention of IUC staff is problematic; this can put additional pressure on the existing workforce, impact on staff morale and create logistical issues with managing annual leave entitlements or scheduling time for training.

This small-scale study highlights some of the complexities of telephone triage work and demonstrates the challenges for IUC service providers in retaining an appropriately skilled and motivated workforce.

Violence directed at ambulance paramedics has attracted increasing public attention because of its major negative impact on the physical and psychological well-being of victims and productivity of organisations. The purpose of this paper is to explore the prevalence of violent incidents, contributing factors, burnout and post-traumatic symptoms among paramedics.

A cross-sectional survey was distributed in two ambulance services in Tasmania and South Australia, with self-administered instruments completed online. In total, 48 respondents completed questionnaires.

There were no significant differences between sites in timing of violent incidents, consequences of traumatic events or organisation provision. Surprisingly, over 90 per cent of paramedics had not been pushed, slapped, beaten, scratched or spat on in the previous month. There was a statistically significant difference between genders for being yelled at or verbally abused (p=0.02). When considering burnout, female paramedics showed significantly higher levels of emotional exhaustion t(37)=–2.32, p=0.02 and lower levels of career satisfaction than their male counterparts, t(37)=3.32, p=0.00.

Although prevalence rates of violent incidents seemed lower than expected, policy interventions to encourage female paramedics to display their professional identities and steps to enhance well-being and safety while on duty should be considered.

The purpose of this paper is to assess the performance measurement in the UK NHS ambulance service documenting various unintended consequences of the current performance framework and to suggest a future research agenda.

The paper reviews the literature on ambulance performance targets and documents several unintended consequences of the current performance system through an in‐depth case study analysis based on interviews with Trust staff and policy experts along with observation of performance review meetings in the chosen Trust. Ethical approval for the study was obtained from a local NHS research ethics committee.

Significant unintended consequences of the ambulance performance targets based on response times have been systematically documented, which are likely to put the target under spotlight, especially that of the eight‐minute response. The current policy focus to reform the eight‐minute target by making it more stringent has the potential of jeopardising the reform agenda based on developing clinical skills of the paramedics and introducing clinical management in the service.

The paper makes an objective assessment of the sustainability of the current policy framework and identifies future lines of enquiry for further research.

This paper makes an original contribution in identifying and documenting the disjuncture between stated and unintended consequences of ambulance performance measurement, which will be of value to academics, practitioners and policy makers.

The purpose of this article to review the literature relating to improving paramedic care in an Australian context.

The paper presents changes and challenges that have occurred in the ambulance services in terms of improving care and measuring performance, exploring the literature on quality improvement initiatives and their application to pre‐hospital care.

While hospitals and health services have moved well down the quality improvement pathway, the application of these processes to pre‐hospital care has been a relatively recent phenomenon. Ambulance services have taken a variety of approaches to measuring and improving pre‐hospital care. This article questions the transferability of lessons learned in hospitals to ambulance services. Arguably, the quality improvement approach is dependent upon health control and funding models and where ambulance is categorised in terms of health or emergency services.

The quality improvement approach by Australian paramedics and ambulance services is in its infancy. This article provides insights into the quality improvement approach taken by ambulance staff in Australia compared to other countries, as well as highlighting useful information on the future direction and research into the area.