The professionalism of ambulance services staff has been highlighted by the COVID-19 pandemic (Awais et al, 2021; Petrie et al, 2022). Nonetheless, inadequate numbers of staff, unmanageable workloads, unrealistic expectations, burnout and moral distress have been compounded by the effects of COVID-19 (Iacobucci, 2021; NHS Confederation, 2021).
Since December 2022, ambulance services staff in England and Wales have taken industrial action for the first time since 1989. The strikes form part of a wave of industrial unrest across a number of sectors in the UK over wages, pensions and working conditions as the cost of living rises. In this context, it is therefore important to focus on the wellbeing and working environment of this vulnerable yet indispensable, group of healthcare workers.
Ambulance services in Wales
Throughout the past decade, NHS ambulance services have seen significant reductions in their budgets, which have impacted their responses and service delivery (NHS Providers, 2020). As a consequence, they are struggling to meet performance targets.
The Welsh Ambulance Services NHS Trust (WAST) is the national ambulance service for Wales, providing emergency services to more than 3 million people across the country. In July 2022, the Welsh Government announced £3 million to recruit more emergency ambulance staff to improve response times for the most serious cases. This funding was made in addition to the £34 million of funding announced in December 2021.
Turnover at WAST is higher than the NHS Wales average, and WAST has the highest sickness absence rates of all NHS organisations in Wales (WAST, 2022). In these circumstances, ambulance services staff in Wales find themselves working in a healthcare environment that is under increasing pressure to meet rising demand and maintain operational resilience and strategic capability, while NHS Wales is unable to recruit and retain staff across all workforce groups and disciplines. The implications for an NHS Wales ambulance service, which is already under pressure, are significant.
Research methods
An online survey was undertaken with the cooperation of ambulance services staff at WAST. The survey was contextualised to reflect the working lives of such employees in Wales.
A working group consisting of Swansea University and WAST staff, including trade union officials from UNISON and the GMB, was formed to manage the launch and promotion of the survey. The online survey was conducted by Swansea University in collaboration with WAST and trade union partners from November 2021 to February 2022. Consent was required from all participants before they could proceed in completing the questionnaires. All potential participants were informed that taking part was voluntary and were assured of their anonymity. The study was promoted to all staff at WAST through internal news bulletins, posters emails and online platforms. These included hyperlinks to the survey website. The online survey was further promoted via social media (Facebook and Yammer). Each of these interventions ensured a comprehensive communication strategy was applied. A total of 594 usable responses were received from 4365 ambulance services staff at WAST (response rate: 13.6%). The authors included a 90% threshold completion of the online survey for inclusion in the study, meaning that any survey that was less than 90% complete was not included.
All survey scales had previously been validated internationally and published (Holland et al, 2018). In addition to answering specific questions, participants were offered opportunities to provide comments. A number of these are included in the present article. Study findings were analysed using standard quantitative and qualitative research methods.
Ethical approval was gained from Swansea University's research ethics committee. In addition, ethical approval was received from the NHS Research Ethics Service on 12 August 2021 (REC reference: 21/HCRW/0017).
Throughout the current article, workplace wellbeing concerns how comfortable, healthy, happy and satisfied staff are working within WAST. Workplace environment explores the internal relationship of WAST to identify the ways in which each area works and supports the effective running of the organisation.
Sample profile: demographics
On average, participants were aged 45 years (SD 11.5) with a fairly even spilt between male (54%) and female (46%) participants. The majority were engaged in full-time work (91%) with 51% employed in operations (51%).
The study's sample demonstrates relatively comparable representation across most demographic indications with the exceptions of over-representation in: medical and clinical services (24% in study versus 1% in WAST); workforce and organisational development (6% in study versus 2% in population); and strategy, planning and performance (2% in study versus 0.3% in population).
Table 1 provides more detailed information on the participants' demographic characteristics.
| Demographic | Study type | Population | |
|---|---|---|---|
| Mean | SD | Mean | |
| Age (years) | 44.48 | 11.48 | 43.92 |
| Tenure (length of time employed at WAST) | 12.55 | 10.09 | N/A |
Research results and discussion
Since March 2020, ambulance services staff have been at the frontline of tackling COVID-19. While the pandemic has impacted all health and social care professional groups, the context of specifically providing acute emergency care for patients with COVID-19 is nowhere more evident than in ambulance services practice (Bergen-Cico et al, 2020).
The pandemic exacerbated and increased pressures on ambulance services in responding appropriately and safely while maintaining adequate staffing levels (NHS Providers, 2020; Beldon and Garside, 2022; Unison, 2022). Indeed, in September 2022, only 50% of calls about life-threatening situations in Wales were reached within the 8-minute target time. This figure is the worst on record since the collection of comparable data began in 2019.
The findings of the present study are in line with other industry-wide indicators. More specifically, they identify that intensifying pressures and demands, exacerbated by increasing staff shortages, bureaucracy and a lack of trust in management, as well as perceptions of being under-resourced, are eroding a positive climate for staff morale and voice within the organisation—and that this affects the care quality and patient safety.
Participants told the authors of feeling entirely ‘worn out’ from ever-increasing workloads and were struggling with working more than 50 hours per week, describing themselves as being ‘machines’. The majority (73%) of respondents indicated they the volume of work they performed was intensive. Half (50%) said this was a frequent and daily occurrence.
Moreover, a significant majority of participants (71%) indicated that their jobs required them to work very fast at least once or twice per day. A similar proportion (75%) reported their job required them to work very hard several times per day. More than half of the participants (60%) reported increasing workloads left them with little time to complete their work at least once or twice to several times a day. One emergency call handler spoke of their concern for colleagues:
‘Listening to the distressing phone calls I receive from road colleagues who are struggling with the 12 hours of continued pressure as forced to work alone with a colleague [military], who is unable to assist. There is no respite from this pressure, especially given in a job which is near to nothing like what they applied to do. I am hugely concerned by my frontline colleagues' welfare.’
In the light of increasing demand and pressures periodically throughout the pandemic, WAST had enlisted the support of the military as part of the Military Aid to the Civil Authorities arrangement. At its peak, 235 armed forces personnel from the British Army, Royal Navy and Royal Air Force were assisting WAST as drivers. This created issues, with the GMB Union lodging a dispute with WAST and writing to the Welsh Government, warning that the use of the military in emergency situations was putting patients and the public at risk while driving down morale among ambulance services staff.
Significant numbers of ambulance services staff spoke of their intentions to leave the organisation. The survey found more than half of participants indicated they either frequently or very frequently considered leaving (52%) and explored alternative career opportunities (54%). Approximately one in five (23%) indicated they were exiting the profession within the next year. As one participant put it:
‘I don't intend to be with WAST much longer… Everyone l speak to is either looking to retire or is actively seeking other employment as they feel the same as l do; which is a terrible shame as we have some really good people working for us.’
Research has widely acknowledged that signs of poor health and wellbeing are increasing, including symptoms of depression, fatigue, stress, trauma, sleep disorders, post-traumatic stress disorder (PTSD), emotional exhaustion, burnout, suicidality and suicide among ambulance services staff (Meadley et al, 2020; Awais et al, 2021; Clark et al, 2021; Beldon and Garside, 2022; Petrie et al, 2022).
Even outside public health crises, evidence suggests that paramedics may be at a heightened risk of mental ill health. In 2019, the mental health charity, Mind (2019), found that 75.8% of ambulance staff in the UK experienced stress and poor mental health while working for ambulance services. In more recent reports, ambulance services staff have reported poorer mental health than police and fire services employees (Mind, 2021a; 2021b). Moreover, ambulance services staff were the most likely to say that their mental health had deteriorated since the COVID-19 pandemic, describing their work as ‘absolutely soul destroying’ (Khaira, 2022).
In the present study, a significant number of participants indicated that they did not feel they received support at work from their organisations, and described the ways in which this affected their mental health. The mean score for organisational support at work was one of the lowest among other indicators at 2.41 out of 5. Moreover, more than half (60%) of participants did not feel their employer cared about their wellbeing, with only 23% indicating that their contributions were valued by their organisation. As to how this left them, one stated:
‘I just feel very unsatisfied in my job. Problems and concerns are voiced often but nothing ever gets done about it. The thought of coming into work makes me very stressed and I often consider going sick due to stress but then don't because I feel pressured by WAST to be in work. Senior management seem to care only for numbers and statistics more than staff wellbeing and happiness, which is unfortunate.’
Another said:
‘I feel so fed up with the job. Poor pay, overworked… Staff morale is at an all-time low. Mental health is also suffering. I feel so fed up and low in mood.’
It is therefore unsurprising that, as mentioned previously, WAST experiences turnover of staff at levels higher than the NHS Wales average and has the highest sickness absence rates of all NHS organisations in Wales (WAST, 2022). This is symptomatic of what is termed ‘moral injury’.
Originally studied in the military context, moral injury refers to a damaging form of distress that often ensues from having to act against one's moral core. More recently recognised in the context of frontline healthcare workers during the pandemic, such moral wound may arise from working under considerable pressure in a health and care system that is ‘log jammed’ (WAST, 2022).
While research on moral injury in the context of frontline healthcare workers such as ambulance services staff remains in its nascent stages, research evidence involving veterans indicates that the experience of moral injury is linked to psychological distress, depression and PTSD symptoms (Moyo, 2015), as well as a reliance on maladaptive coping strategies (Williamson et al, 2018).
Given the recognition that trust is an integral factor in organisational success and stability, as well as employee wellbeing, the present survey sought to explore the perceived levels of trust that healthcare workers have in both senior management and direct supervisors.
The survey asked participants several questions regarding their trust in senior management and direct supervisors. More than one in four (28%) indicated they were confident that senior management would always treat them fairly; however, half of them disagreed or strongly disagreed with this statement. While nearly one in four (22%) participants felt that senior management sincerely considered employees' points of view, more than half (56%) did not share this perspective. One staff member said:
‘I have no confidence in the top management at all. They simply do not care about the crews on the road. We are simply just a number that can be used up and replaced.’
This participant has been working in ambulance services for four decades:
‘Senior management have become so disconnected from frontline staff. mainly through demonstrating a total lack of consideration, along with a disregard to staff welfare and wellbeing. All this was prior to COVID-19, which has added to the burden to the point that I feel exhausted. I have been in this service for 40 years. I'm very proud of my career and the fulfilment it has rewarded me with. Sadly though, I can no longer recommend it as a career path, which saddens me immensely.’
Another said:
‘We are made to feel like our efforts are worthless from senior management. We are lied to and treated like cannon fodder. So much to the extent that I have recently felt the need to completely take some time away from work for my own mental health. In a short space of time away from work, I was calmer… slept better and was close to my immediate family again. In the short space of time that I've been back at work, the old problems are emerging… worrying about work.’
Taken together, the general lack of trust in senior management is particularly concerning. In these circumstances, participants spoke of the importance of support from family, friends and social networks outside the organisation. The majority (81%) of respondents reported that their family members have supported their participation in the workforce, with 83% indicating their family members understood they had to fulfil duties in both work and family domains.
Limitations
Non-response bias or systematic differences (for example regarding gender or age) among respondents and non-respondents may potentially influence the differences in responses (de Vaus, 2002). This can undermine the external validity of findings (Rogelberg and Stanton, 2007). Given the online recruitment of participants and anonymous nature of the survey, assessments of non-response bias were not possible. However, comparison of the demographics of respondents against the national statistics indicated tha the sample is relatively consistent and reflective of wider ambulance services staff populations, suggesting minimal non-response bias. Nonetheless, the authors recognise that potential limits may be placed on the external validity of this study's results (Rogelberg and Luong, 1998).
Moreover, the data are self-reported. Although suitable in examining employees' attitudes and perceptions, the data may fall short in capturing complete knowledge such as organisational practices.
Conclusion
This article offers a contemporary portrait of working life for ambulance services staff within WAST. This study recognises that the multifaceted nature of working conditions and staff wellbeing within the organisation requires significant review.
The survey explores multiple factors of workplace wellbeing. Specifically, the results relating to work intensification, burnout and intention to leave, raise concerns regarding increased and competing demands and time pressures, and the ways in which these impact the wellbeing of ambulance services staff, care quality and patient safety.
The results on burnout among ambulance services staff reinforce the fact that work intensification is impacting staff wellbeing and intentions to leave the profession. As a consequence, ambulance services and their staff in Wales are reaching a tipping point. If issues are not addressed positively, the outcome will most likely be a further acceleration of highly skilled staff, who are expensive and difficult to replace, leaving the organisation.