LEARNING OUTCOMES
After completing this module, the paramedic will be able to:
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The idea that leadership is associated exclusively with positions of authority is outdated (Stanley, 2017). Leadership is an ever-developing concept with modern models and frameworks being developed around the world (Ardichvili et al, 2016). Johnson et al (2018) explained that leadership is a social construct that has no exact definition.
In healthcare across the UK, the current focus of leadership is on each individual employee, not just authority figures, as there is a wealth of literature now outlining the fundamental differences between leadership and management (Stanley, 2017). While appreciating that leadership is important within organisational management, there are many reasons that can be argued to emphasise why each individual clinician should be demonstrating leadership qualities (Bird, 2020). Examples include: improved patient safety, interprofessional teamwork and self-management.
The NHS Clinical Leadership Competency Framework (CLCF) (NHS Leadership Academy, 2011) outlines clinicians’ responsibility to practise leadership effectively (Daly et al, 2014). Specifically, paramedic leadership characteristics are centred around the first two domains of this framework, which focus on personal qualities and working with others. Nonetheless, the other domains are also relevant to clinical practice (Daly et al, 2014).
This article will discuss leadership characteristics, which are personal and professional qualities that contribute to the delivery of high-quality patient care, as well as leadership within paramedic practice (Johnson et al, 2018). These include but are not limited to social and emotional intelligence, management of stress, teamwork, mentoring, management of conflict, self-awareness and professional integrity.
Leadership is a crucial element of paramedic practice and is implemented in a vast variety of situations (Johnson et al, 2018). The Health and Care Professions Council (HCPC) recognises the importance of leadership within the paramedic profession. Paramedics must adhere to standards of proficiency 8.6–8.10, which concern the application of leadership in practice (HCPC, 2023). The HCPC recognises that all clinicians should act as leaders, especially in the recent years following a global pandemic (Bird, 2020).
Paramedics can improve their leadership through education, personal experience, continuing professional development (CPD) and reflection. Building the knowledge that each clinician requires to demonstrate these qualities is crucial to development (Waller, 2022).
Leadership characteristics within prehospital care continue to be developed from other professional fields, such as aviation, to improve non-technical skills and patient safety (Dagnell, 2020). An example of this is the widely implemented crew resource management (CRM) model used in the aviation industry, which can promote a safety culture and, in return, reduce blame culture (Dagnell, 2020).
Despite the focus of leadership within this review being directed towards burnout, the literature recognises that it is beneficial for many other reasons, including a higher quality of care, improved patient safety and a reduction in harm, as well as contributing to healthy team climates (Taylor and Armitage, 2012).
Burnout: current climate
Burnout is prevalent in ambulance services (Ambulance Staff Charity (ASC), 2022). Beldon and Garside (2022), having thematically analysed a large sum of qualitative papers, reported that more than 50% of ambulance staff are experiencing burnout symptomology, and this is supported by a broad range of heterogenous literature and research. Hayes' (2020a) structured analysis of 15 quantitative studies also concludes that frontline ambulance workers are subject to high levels of burnout.
This article uses Maslach's Burnout Inventory Human Services Survey (MBI-HSS) adapted for medical personnel, which describes burnout symptomology as emotional exhaustion, depersonalisation and feeling a lack of personal accomplishment (Vincent et al, 2019).
Burnout is an assemblage of emotional, mental and physical exhaustion (ASC, 2022). Examples of factors that contribute to this in ambulance services across the UK include long hours, physical demands, incivility and service misuse (Beldon and Garside, 2022). This article aims to provide an understanding of how paramedics can navigate these difficulties and therefore reduce the likelihood of becoming affected by them. It is important to recognise that factors such as ambulance service demand, policies and resources are limitations that are outside of the control of an individual paramedic (Harrison, 2019).
The concept of burnout became more widely recognised after a German psychologist called Herbert Freudenberger released his original paper in 1974 describing burnout as becoming exhausted through excessive demands being made on energy, strength or resources (Heinemann and Heinemann, 2017). Burnout is an increasing problem among paramedics. Reardon et al (2020) conducted a systematic review, which confirmed its prevalence.
Burnout can involve a long list of symptoms; however, these differ between each affected individual (Beldon and Garside, 2022). Powell et al (2020) found that paramedics increasingly require resilience to prevent burnout.
This article explores how leadership characteristics could help individuals to navigate this. Burnout is a complex issue that can have detrimental effects on a paramedic's career (ASC, 2022). The symptoms can limit one's ability to practise prehospital care safely and compassionately (Reardon et al, 2020).
Having reviewed current literature, this article will explore emotional intelligence, stress and conflict to show how leadership characteristics can reduce some factors contributing to burnout in the hope that this can reduce staff attrition and absences (Table 1).
| Leadership characteristi | How it can be developed |
|---|---|
| Emotional intelligence |
|
| Stress management |
|
| Conflict management |
|
Reflection 1
Do you implement aspects of modern leadership into your work? If yes, what are these and what effect do they have?
Reflection 2
Have you ever experienced burnout or come close? What were the indications and do you think they could have been stopped?
Emotional intelligence
While emotions can be positive or negative, emotions perceived by society as negative can have helpful purposes (Issah, 2018). Emotions drive actions, so must be regulated to ensure people act appropriately and effectively (Kozubal et al, 2023).
The concept of emotional intelligence flourished in 1995 thanks to American psychologist, Daniel Goleman. Goleman (2009) suggested that emotional intelligence was based on the following five components:
An understanding of these components is crucial to the development of a strong leadership identity. This can allow prehospital clinicians to better control their responses to strong emotional circumstances, which they will inevitably come across throughout their career in community healthcare.
Lambert (2018) carried out a quantitative correlation study as part of his leadership dissertation, which found that student paramedics with higher levels of emotional intelligence were more successful. Although this paper originates from America, its findings link well with paramedic practice within the UK and convey the importance of emotional intelligence.
Five pillars of emotional intelligence
First, self-awareness is knowing when you are experiencing emotions, and what you feel in certain circumstances (Issah, 2018). This state of emotional maturity links strongly to paramedic practice. As out-of-hospital clinicians, paramedics are subject to many emotional stimuli, and it is important they are aware of these to prevent bias or changes to patient care (Hurley and Linsley, 2012).
Second, self-regulation is controlling the way you act when experiencing emotion, especially in moments of impulse (Kikanloo et al, 2019). Being able to channel these reactions will mean an individual can think and rationalise before they speak or act (Kikanloo et al, 2019).
Motivation is having a drive for improvement and striving for personal and professional development (Issah, 2018). Particularly in times where obstacles or challenges may be present, motivation is having the perseverance and strength to work through these (Northouse, 2022). Given the challenges facing the NHS at present, ambulance staff must stay motivated to reduce burnout within the profession (Mathew, 2022).
Regarding empathy, Williams et al (2017) discussed a strong link between paramedic burnout and empathy in a scoping review. The paper describes how paramedics can control their capacity to empathise; therefore, as clinicians develop their emotional intelligence, they will reduce the risk of emotional burnout. However, the author does recognise a paucity of literature specific to paramedicine in relation to this topic.
Finally, Goleman (2009) includes social skills to complete the five pillars of emotional intelligence. Positive communication can contribute to better rapport with both patients and other employees, further improving job satisfaction and, as a result, reducing risk of burnout (Goleman, 2009).
Hayes et al (2020a) highlighted the importance of emotional regulation for psychological wellbeing in paramedic practice. Their study investigates the concept of emotional labour, which is practised often by prehospital clinicians and is the idea of suppressing emotion to maintain professionalism in front of patients and their families. As research has proven that emotional detachment does not align with clinical competence, Hayes et al (2020a) explain that emotional intelligence will allow paramedics to compassionately care for patients and their families in difficult situations. Furthermore, there has been great emphasis on emotional regulation for paramedics, as the recent COVID-19 pandemic presented emotional challenges which will affect practice for years to come (Hayes et al, 2020b).
Stress
The nature of emergency ambulance care can involve both stressful situations and cumulative, chronic stress (Davis et al, 2018). Clinicians such as paramedics are subject to many degrees of stress throughout their careers. Increased frequency of stress over time does lead to burnout, which can further result in staff absence or resignation (Ocean and Meyer, 2023).
What is stress?
Stress is an autonomic human response to a stimulus that appears threatening to an individual (Roozendal et al, 2009). Because people differ regarding how their prefrontal cortex works, what one person may see as a threat might be different to another based on the individual's own perceptions and assumptions (Kredlow et al, 2022). The amygdala triggers a ‘fight or flight’ response in the brain and the hypothalamus allows for adrenaline and cortisol to be released into the bloodstream (Roozendal et al, 2009).
Impacts of stress
Stress, especially over long periods of time, can have an extensive number of impacts on not only physical health but also mental and emotional wellbeing (NHS, 2022). If stress is not managed appropriately, it can soon turn into distress.
Physical health is affected by stress in many ways including poor digestive health, headaches, muscle aches and inflammation, as well as altered sexual health and fertility (Yaribeygi et al, 2017). In addition to these chronic problems, stressful situations can alter a person's heart rate, respiratory rate and urinary output because cortisol and adrenaline are released during a fight-or-flight response (Gallacher and Whiteley, 2013).
Mental health is also affected, with depression being the main condition related to stress. This is a result of reductions in serotonin and dopamine in the brain caused by cortisol's effect on neurotransmitters (Gianaros and Wager, 2015). Impaired memory, reduced sleep and racing thoughts are also linked to stress (Yaribeygi et al, 2017).
Many mental and physical health detriments linked to stress can be related to the bottom, fundamental row of Maslow's hierarchy of needs (Gorman, 2010). The physiological requirements for sleep and a healthy digestive system are crucial for a paramedic to stay focused and maintain patient safety (Yaribeygi et al, 2017). In an investigation of paramedic resilience, Clompus (2014) found that reduced sleep was a common theme among participants. This further highlights the risk of the job to physiological needs.
Emotional and behavioural wellbeing can be impacted by stress (NHS, 2022). People can become angry or sad and, importantly, lack compassion as they develop stress and burnout symptomology (McKerrow et al, 2020). Since 1908, a variety of performance curves have been developed to illustrate understanding of where optimum performance sits between ‘boreout’ and burnout (Martinss, 2020). These highlight that emotional impacts such as worry and anxiety sit very close to burnout, and the area of the curve where people feel overwhelmed (Gianaros and Wager, 2015).
Stress-management solutions
To prevent burnout and maintain their own psychological and physical health, paramedics can adopt many strategies (Duschek et al, 2012). By doing this, they could improve job satisfaction and reduce the risk of leaving the profession.
To display leadership, paramedics should engage in social or peer support (Lowery and Stokes, 2005). This involves communicating with family, friends or colleagues to offload stressors they are experiencing (Lowery and Stokes, 2005).
Despite its therapeutic value, dark humour is argued to be less healthy and has the added risks of becoming offensive or inappropriate, so would not display as strong a leadership identity as other tools (Christopher, 2015).
Talking-based therapy and counselling can reduce stress but their formality can sometimes be less popular with ambulance professionals than informal discussions with peers (Mildenhall, 2013). This is often because of pride and a fear of embarrassment (Mildenhall, 2013).
Paramedics should encourage and promote such discussions with colleagues, for example, in the station mess room. While recognising the paucity of literature in this area, Mildenhall's (2013) literature review suggests this form of peer support to be the most effective. If this is not appropriate or not working, ambulance clinicians in the UK can reach out to support services, such as the ASC (2022) for 24-hour phoneline support to discuss any worries.
To further display leadership, clinicians could write reflections or facilitate and engage in debriefs to reduce the chance of becoming stressed. This is recommended to practitioners in the CLCF (NHS Leadership, 2011).
Lastly, paramedics can take part in mindfulness-based stress reduction, which has been found to relieve stress and anxiety and, specifically, to improve interactions with patients and colleagues in the workplace (Praissman, 2008). Donald et al (2018) also found mindfulness to have a positive influence on social behaviour.
Reflection 3
This article discusses individual efforts to tackle burnout. What role do you think organisations such as ambulance services or the College of Paramedics play in tackling this and are they effectively doing so?
Stress-management limitations
The literature suggests that admitting to being negatively affected by stress is challenging for ambulance clinicians as it can be perceived as a weakness and lack of resilience (Donnelly et al, 2016). This stigmatisation makes it harder for paramedics to forwardly admit to stress and burnout in the prehospital environment.
Promoting honesty and transparency in relation to emotions and seeking help when required would be good examples of leadership characteristics that can be implemented in prehospital care (Cooper et al, 2023). If health professionals were to display these leadership characteristics, the workplace culture surrounding stress could vastly improve throughout paramedicine. Availability of support services also depends on where a clinician works and this could limit how well each individual paramedic could manage their own stress (Johnston et al, 2022).
Missed meal breaks, late finishes and hospital waiting times are limitations outside of the individual employee's control, which contribute to stress and reduced motivation (Stott, 2016).
Kirby et al (2016) highlight a paucity of literature surrounding employers’ contributions to burnout, which highlights the importance for further research to be carried out so organisations can navigate these issues.
Conflict
Conflict arises interprofessionally in healthcare as well as between service users and clinicians. Conflict is a social construct surrounding argument or disagreement, which is often referred to in a negative context (Brown et al, 2011). However, it can have beneficial uses in paramedicine as challenges can often lead to change in line with an up-to-date evidence base (Ramsey, 2001).
By maintaining a leadership identity, a paramedic can manage conflict professionally and positively. To do this, clinicians must actively listen, seek solutions, avoid blaming others, work together to address issues, and reflect (Bourne, 2023). This can be referred to as functional conflict; improperly managed conflict can be referred to as dysfunctional conflict (Rahim, 2010). It is also important for conflict to be managed functionally to prevent ripple effects limiting patient care and best practice (Cullati et al, 2019).
It has been reported that the incidence of violence and aggression towards ambulance staff is increasing, with government-level policy being implemented to try to tackle this issue (Rees et al, 2022).
Interprofessional conflict, both verbal and non-verbal, can chronically affect job satisfaction and overall burnout (Credland and Whitfield, 2022). Cases of incivility between ambulance and emergency department staff can result from many external factors; in addition to conflict resolution strategies, better-managed emotional and social intelligence can help to address this (Brydges et al, 2022). Parvaresh-Masoud et al (2021) stressed that conflict can be detrimental to a healthy work and team climate, as well as to an individual's physical and psychological health. By having an awareness of how to functionally manage conflict, a paramedic can demonstrate leadership by navigating an area that has been shown to have cascading effects that lead to burnout (Credland and Whitfield, 2022).
The five avenues of conflict management include: competing, compromising, collaborating, accommodating and avoiding (Adkoli and Pawar, 2018). It can be difficult to balance assertiveness and cooperation, and these strategies could direct a leader to pursue a course of action based on each unique situation. These functional directions can be considered and displayed as part of a strong leadership identity to positively manage conflict and reduce the overwhelming nature of conflict on a clinician (Russell, 2022). However, there are some barriers that must be considered to create a holistic understanding of conflict management. Examples of these are poor emotional and social intelligence, personal opinions and different perceptions of a situation (Bar-Tal, 2010).
Reflection 4
Have you ever experienced interprofessional conflict within a healthcare setting? Was this managed functionally?
Future leadership development
This article intends to promote leadership within the prehospital workforce and explores leadership characteristics relevant to all paramedics. An increased awareness of these qualities will improve paramedics leadership abilities and this, in turn, will reduce the prevalence of burnout. The leadership qualities discussed are recommended for implementation in practice, not only to improve individual leadership skills, but also to allow clinicians to act as role models (Johnson et al, 2018). The literature suggests that behaviours can positively influence others, and therefore these characteristics have the potential to drive positive cultural improvement (Armstrong, 2013).
To further develop leadership qualities, paramedics should take part in CPD activities, carry out reflective practice, complete further education and take up employment opportunities such as secondments or promotion (Waller, 2022).
While this article focuses on frontline paramedics, it is important to recognise the influence of wider factors such as employers, organisations and education (Beldon and Garside, 2022). Ambulance trusts are responsible for the wellbeing of their staff and must demonstrate good leadership, which includes listening to employees, promoting health and wellbeing, taking appropriate action and being receptive to change (NHS, 2023).
Ambulance employers across the UK have implemented many policies such as fatigue and meal-break policies to try to tackle the working conditions that contribute to burnout (Yorkshire Ambulance Service, 2024). However, the NHS National Staff Survey (2023) found ambulance staff to have concerns over the leadership and management being delivered on a national level. Further research into this area is required so practical recommendations can be made (Kirby et al, 2016). Nonetheless, these concerns should highlight that everyone has a part to play in navigating the contemporary issue that is burnout.
Reflection 5
Everybody has different ways of managing stress outside of work. What activities do you partake in to reduce stress? How effective do you find these methods?
Conclusion
Unprecedented occupational challenges continue to test paramedics. There is more demand on ambulance services than ever before (Reardon et al, 2020). With this increasing workload comes rising pressure to work and perform effectively. However, this climate is testing prehospital clinicians to the limit, resulting in stress, fatigue, and exhaustion (ASC, 2022). With an increasing prevalence of burnout, paramedics should develop positive leadership characteristics to navigate the factors contributing to this issue (Hayes, 2020a).
An awareness of emotional and social intelligence and how to apply these could improve resilience within the profession. (Williams et al, 2017). It has been suggested that a functional leader should no longer become deflated or burnt out by conflict, but functionally engage in it to holistically understand a situation and external perceptions (Rahim, 2010).
Finally, by maintaining a strong leadership identity, paramedics will be able to understand stress and explore how best to manage themselves at times where they feel symptoms of burnout occurring (Duschek et al, 2012).
The problems facing prehospital care may not always be tackled by services or employers so paramedics must act as agents for change. By implementing transformational leadership characteristics, clinicians – both as individuals and collectively – can improve organisational cultures and occupational barriers that are contributing to burnout and attrition across the profession (Al Amin et al, 2023).