The West Midlands Ambulance Service NHS Foundation Trust successfully recruited 10% of their applicants from black and minority ethnic groups (BME) in 2011–2012. This fell to approximately 3% in 2012–2013 (Jabeen, 2012). The total proportion of applicants to the service from BME groups also fell, from 20% to 17.93% during this same time period (Jabeen, 2012). When considering the NHS Ambulance Service as a whole, from January to August 2012, only 3% of their workforce is made up of individuals from BME groups, a stark contrast with London Ambulance Trust, whose workforce is made up of 9.3% from BME groups (Jabeen, 2012). However, there is a paucity of evidence providing reasons for the low frequency of BME individuals applying to and gaining employment with the ambulance service. This study sought to identify potential barriers to BME groups for gaining employment or training within West Midlands Ambulance Service NHS Foundation Trust.
Background
A literature search was conducted (circa 2000 to mid-2013) with the purpose of gaining a better understanding of the potential barriers for BME groups to accessing paramedic education. Literature specifically relating to paramedic education was limited and therefore evidence was drawn from wider sources including; nursing and other healthcare related courses as well as the uniformed services (armed forces, police and probation, fire service).
Barriers to healthcare education and uniformed services
Maybe the most prominent barrier to healthcare and uniformed service employment as identified by BME groups is that of institutional racism (inequalities within organisations based on race), particularly in the police and probation service (Macpherson, 1999; Ishaq and Hussain, 2001; Hussain and Ishaq, 2002). Racial discrimination (unintentional or conscious), when being in receipt of a service or applying to a join service, has also been identified (Lewis and Smith, 2002; Darr and Archibong, 2004). A lack of cultural competence, such as cultural awareness training for existing staff has also emerged as a potential barrier (Johnson, 2010). Also arising from the literature was a belief that policies put in place to deal with racial disputes would not be correctly implemented (e.g. Hussain, 2003). A lack of knowledge in relation to career progression (e.g. senior positions in nursing) and cultural and religious allowances (e.g. wearing of religious garments) has been identified as deterring some individuals from BME group from entering into these professions (Ishaq and Hussain, 2001; Hussain, 2003; Darr and Archibong, 2004). Influence from family or friends is seen to encourage or dissuade an individual's career decisions, as in particular, family views are valued highly in some cultures (Ishaq and Hussain, 2001; Hussain and Ishaq, 2002; Daly et al, 2003; Heer and Atherton, 2008). The literature also suggests that role models (potentially from the same BME group as an individual) are needed to avoid certain professions from being overlooked (Daly et al, 2003; Hussain, 2003), and in order to inspire individuals in shaping their career goals by aspiring to someone who is from a similar background (Daly et al, 2003). Lastly, advertising campaigns aimed at BME groups may be failing to connect or influence their target audience or failing to promote paramedic education effectively (Hussain and Ishaq, 2002; Hussain, 2003).
There is a lack of knowledge as to the specific barriers to paramedic education for BME groups. It is also not understood which methods of recruitment and generating interest is most successful for paramedic and ambulance services who are trying to recruit more individuals from BME groups.
Aims and objectives
The aim of this evaluation was to understand how individuals from BME groups respond to careers information that is presented on, by and for the West Midlands Ambulance Service NHS Foundation Trust and West Midlands Higher Education Institutions. The evaluation also aimed to gain an understanding of experiences of the enrolment process and training for paramedic science courses, in order to identify potential barriers. The following information was analysed:
Approval
This evaluation was granted approval by the West Midlands Ambulance Service NHS Foundation Trust; and permission to undertake and publish from this study was provided by service.
Methods
A semi-structured interview schedule was designed in order to gain knowledge of respondents' routes into paramedic science or training, prior knowledge and information, expectations and experience of the role and training, application processes, support from family/friends, recommendations of the profession, and suggestions of improvements to widen participation. Interviews were undertaken by the Principal Investigator who was not known to participants and was not involved in paramedic science courses or the recruitment of individuals to paramedic science courses. The interview schedule was informed using the aims of the study, feedback from the West Midlands Ambulance Service NHS Foundation Trust and findings from the literature review.
West Midlands Ambulance Service NHS Foundation Trust provided contact details of staff who disclosed their ethnicity as belonging to a BME group. A total of eight individuals responded to invites and confirmed participation.
Respondents received an e-mail information sheet outlining the evaluation, and a consent form. They were requested to complete and return the consent form via e-mail before taking part in the interview. Respondents attended at a time most convenient for them. We conducted interviews via telephone and recorded responses using a Dictaphone.
Six respondents took part in telephone interviews (75% response rate) between June and October 2013.. Five respondents were qualified paramedics (two recently qualified), with up to 17 years of experience. One respondent had not yet completed their FdSc Paramedic Science course. Four respondents entered the paramedic service through university. On average, interviews lasted approximately 29 minutes. Recorded interview files (mp3 format) were transferred onto a computer and transcribed verbatim using computer software for playback and transcription purposes (NVivo 10). Recordings were then replayed and transcripts were checked for accuracy. Thematic analysis was used in order to analyse the qualitative data obtained from the interviews. A majority of the themes included in this analysis were taken from the types of questions asked in the interviews, and responses were coded into different themes using NVivo 10. Some responses were coded under more than one theme if a response related to something other than the question being asked. Transcripts were also hand-searched to identify any other emergent themes that were not directly related to the interview questions. To minimise bias, themes were cross-checked by other members of the research team. Emerging themes and responses will be examined here.
Results and discussion
Career choice
Varied reasons for entering into paramedic science courses or employment arose, from respondents being influenced by external factors, such as witnessing injury, experiencing related services (e.g. first aid courses) and being influenced by other people, to joining the service simply for employment;
‘I had an experience at work, when I wasn't a first-aider, where someone had fallen over, had a heart attack, cracked his head open, blood everywhere…that was a big like eye opener for me, that like pushed me…’ (Participant PRW201)
It is important to note that none of the respondents reported being influenced by promotion of paramedic science by the ambulance service. This finding advises that there may be a lack of successful promotion for this type of profession, which is conducive to the findings of Hussain (2003) in relation to promotion of careers in the British Armed Forces for BME groups. Furthermore, only one respondent reported knowing someone in the ambulance service, prior to enrolling onto a paramedic science course, which supports the findings of a potential lack of role models for BME individuals in relation to healthcare or uniformed service professions (Daly et al, 2003; Hussain, 2003). A majority of respondents actively searched for more information on paramedic science. There was only one respondent who joined the ambulance service approximately a decade ago, who reported seeing advertising from an ambulance service at the time. This also suggests that, perhaps, the choice to enter a career such as paramedic science may be more influenced by experience rather than simply being informed about the role.
Sources of information that were sought by respondents regarding careers in the paramedic included information from universities, the NHS Careers website, contacting the ambulance services directly, and using internet search engines. University prospectuses and NHS Careers websites were described to encourage respondent's decisions about going into paramedic science. These findings may suggest that advertising for this profession is not salient or is not reaching a diverse audience. Responses also suggested a need for information from people working in the ambulance service themselves, e.g. information on a typical day in the service or what staff may encounter. Having sufficient prior knowledge of a profession may encourage a person's decision as to whether they wish to pursue a career, as this has been identified as a barrier for other professions, such as nursing (Daly et al, 2003; Darr and Archibong, 2004), the fire service (Ishaq and Hussain, 2001) and the armed forces (Ishaq and Hussain, 2001; Hussain, 2003).
Responses also suggest that the ambulance service does not portray a diverse image, with a lack of BME individuals and women being noticed when in the community;
‘…because the ambulance service, unfortunately has an image, and it's true, drive past most ambulances…the majority it's overweight men, white men, older white men.’ (Participant PRW204)
This is comparable to the findings that a lack of role models in similar professions may discourage individuals from BME groups from entering said profession (Daly et al, 2003; Hussain, 2003). Only a minority of respondents reported issues that were related to ethnicity, which may suggest that not all BME individuals encounter the same experiences when entering into the paramedic service. Issues relating to ethnicity were mentioned in relation to reservations about joining the ambulance service, and the possibility of being the only BME staff member;
‘Yeah there was some…reservations…because again it was mainly down to there is no other Asian, Black member of the ambulance service that you know.’ (Participant PRW214)
A majority of respondents perceived positive attitudes towards their chosen profession from family and friends, with encouragement gained from these relations, which is in contrast to findings about similar services such as nursing or the police service (Ishaq and Hussain, 2001; Daly et al, 2003). However, negative attitudes from friends and family did not seem to discourage career choice. Some views suggested that a few individuals may hold a stereotypical image of the ambulance service, implying that someone may not fit in, although this was not in relation to ethnicity. Concerns were also expressed from relations in terms of family dynamics (e.g. being a lone parent).
Expectations of the role
A lack of understanding of the role of a paramedic was identified by some of the respondents in relation to their thoughts prior to enrolling onto a paramedic course. Not knowing what the course or role entails may discourage individuals from entering into the ambulance service, or may lead to attrition if someone's perception of a role is very different to the reality;
‘I didn't really know full on what it entailed, or how much responsibility it was going to be…or how much knowledge I would of needed to of known.’ (Participant PRW201)
Prior and current perceptions seemed to differ greatly in terms of the experiences that would be encountered in the role. For example, one participant expected to witness more complex injuries in their day-to-day role and another did not envisage a large proportion of their role to be dedicated to social, rather than medical issues. This evidence again supports the idea that there is a lack of information on the role of a paramedic and what their day-to-day duties involve.
‘I guess I just thought like learning skills… practical side of things…I expected to see more trauma’ (Participant PRW201)
‘…the fact that you deal with so many social issues…from what the media would have for paramedics, it's like everything, it's the adrenaline going…Whereas the majority of the work, is like, you know social issues, overdoses…’ (Participant PRW204)
This suggests that a more realistic image of becoming a paramedic needs to be disseminated in order to supply more knowledge to individuals, and avoid attrition after recruitment (Cashmore, 2002).
Enrolment
There were a few issues relating to applying for a paramedic science course, with individual issues concerning student finance and access courses. Responses in relation to the interview process brought about mixed views, including issues relating to the relevancy of the questions asked, including some deemed as inappropriate where a respondent reported being repeatedly questioned about their ethnicity.
‘Well my hair was down to my shoulders… bearing in mind this was 1989. His first question was “Are you a Sikh?” His subsequent questions were, “where do you come from?”’ (Participant PRW206)
This may act as a potential barrier to entering the profession if relevant questions are not asked, or irrelevant questioning creates tension, due to discrimination (Lewis and Smith, 2002). Participants suggested that giving them further information from a practising paramedic would better the interview process.
‘I think maybe, possibly having one person from the ambulance service on the panel… that might help us get more of an insight into the ambulance service.’ (Participant PRW202)
Perceptions of the type of people presently acting as paramedics (i.e. overweight men), gave rise to questions regarding the fitness test conducted during the interview, and whether it was fair to test candidates on something that some current paramedics would not pass, portraying an image that does not mirror reality (Cashmore, 2002).
‘Probably not done the fitness test…you see paramedics out there now that are like really unfit…if they were to do a fitness test now, they wouldn't pass, and yet they're still paramedics. So that, to me, doesn't really show that you need to be fit to be a paramedic.’ (Participant PRW201)
Furthermore, this finding reflected the lack of role models provided by the ambulance service if a potential candidate for a paramedic course cannot envisage themselves in the role as they do not currently see paramedics who look like them.
Experiences of training
Experiences of training and the paramedic course suggest that more training may be needed for practising paramedics who act as supervisors during course placements, in terms of being prepared to work with trainee paramedics who have undertaken the university route, and having an awareness of students' level of knowledge in relation to the stage of their course. However, these views were not held by all respondents;
‘I was surprised, really surprised at how negative so many paramedics are towards, especially towards paramedic students, the university route.’ (Participant PRW204)
Responses also suggest a possible need for a wider range of skills to be taught for students to feel more comfortable in dealing with specific situations.
‘…but really I feel like children… paediatrics and maternity and mental health…we need to learn more about those areas’ (Participant PRW201)
Furthermore, this finding again supports the need for candidates for paramedic courses to be fully informed in relation to the duties of their future role.
Communication and support from lecturers and fellow students were mainly conducted through social media or email, which though convenient, caused issues for some individuals who may not use these services, leading to possible segregation within student groups due to a lack of communication with lecturers and peers. Factors such as age or external responsibilities (e.g. having children) may also have accentuated segregation.
‘…because they knew I had a little one (child) and had to go home, they didn't make any effort.’ (Participant PRW204)
Respondents' opinions varied in terms of support systems during training. However, support from peers was viewed positively by some respondents due to peers having similar experiences. Perceptions of lecturers not being adequately prepared to teach and train prospective paramedics also emerged.
‘The lecturers…They hadn't trained to be teachers …uni must have put them through some kind of course, but their true vocation is not to be a teacher…They say things and you're automatically expected to understand.’ (Participant PRW204)
Issues relating to working patterns were identified as causing the profession to be less appealing to people with certain responsibilities (e.g. lone parents).
‘…no one mentioned things like the shifts, the unsociable hours…and I found those kind of things, I wasn't prepared…because I would of made slightly better decisions in regards to child care.’ (Participant PRW204)
Although participants expressed positive opinions of on-the-job training, there were misconceptions of the role from the student, but also in relation to the expectation of training supervisors.
‘Yes and no…we had knowledge and it was available…I think a lot of people (supervisors)… they didn't understand what you were allowed to do with a first year student.’ (Participant PRW204)
Peer support and sharing experiences was seen as a way of feeling more prepared for certain situations.
‘…you pick up from then you know just by talking to your peers.’ (Participant PRW214)
Improvements
Improvements to the promotion of paramedic science included; more public presence and promotion (e.g. in schools and colleges), and increased community engagement to provide the public, and potential candidates, with more knowledge on what the role of a paramedic involves and the range of services provided by the ambulance service (e.g. triage work). This may increase potential candidate knowledge and avoid a narrowed perception of this type of profession (Ishaq and Hussain, 2001; Hussain, 2003; Darr and Archibong, 2004).
Recommending the career to others
All respondents stated that they would recommend becoming a paramedic to others.
‘Ah, definitely! Spot on, every day of my life I'm like, guys, I wish you guys would just go on an ambulance for one day, just to experience what I go through. It's the best job ever!’ (Participant PRW201)
This suggests that there may be promotion of the profession from members of the BME community who are already employed by the ambulance service; however, these respondents also revealed that they would be open in not recommending the profession to certain individuals if they did not hold the characteristics they believed were required to work in the ambulance service.
‘If I thought they were strong in character, then I would recommend it. If I thought they were soft and slightly meek in character, no way.’ (Participant PRW206)
This indicates a stereotypical perception of the type of person that would ‘fit-in’ to this role. The response of one interviewee, stating that they would not want their own children to enter into the service, but would recommend other people, as they want their children to do ‘better’, indicates a possible negative view of the career prospects, or that it is not viewed at the same level as alternative professions. However, as there were no interviews with non-BME respondents, it is difficult to ascertain whether this is a possible attitude held only by BME groups (Ishaq and Hussain, 2001; Daly et al, 2003; Hussain, 2003).
Other emergent issues
Although all of the issues mentioned above come from a sample of BME respondents, they may not all be necessarily restricted to issues faced by BME individuals entering into the paramedic science. Issues relating to diversity and, in particular, ethnicity also emerged through participants' responses.
Having dependents may dissuade individuals from joining a service that operates varying shift patterns and unsociable hours, with a lack of support for lone parents being expressed by one respondent;
‘In fact, this degree does not do anywhere near enough support for parents. There's just no support network.’ (Participant PRW204)
Experiencing stereotypical perceptions of BME groups from non-BME peers on paramedic science courses and during training also emerged.
‘they all think you're going to speak like you're from the “hood”’ (Participant PRW204)
Some respondents revealed inappropriate communication in relation to ethnicity from non-BME members of staff/students;
‘One particular person was more interested in who I was and what I was and my colour and ethnicity.’ (Participant PRW206)
Perceptions of racially insensitive communication, discrimination and feelings of segregation from non-BME students was also among the emergent barriers.
‘I not only faced adverse racism as they say externally, when attending work, but also internally as well…opportunities were made available and I'd go for those opportunities, it was seen, it was done as a token gesture as such.’ (Participant PRW214)
These experiences, once already training to become a paramedic, possibly contribute to student attrition and reflect a lack of cultural competence (Johnson, 2010). The lack of visible BME members of staff already working for the paramedic service for students but also in the community indicates a possible lack of role models for BME students who are considering entering into paramedic science.
‘I never once saw an ethnic minority, of any kind. Not even helping out.’ (Participant PRW204)
(in relation to the environment now as compared to when they joined the service): ‘I still feel that we are a very indigenous, white organisation, West Midlands Ambulance Service…you probably would never see a BME member of staff out there in the community.’ (Participant PRW214)
Again, this related to a lack of role models for this type of career (Daly et al, 2003; Hussain, 2003).
Limitations
Using both BME and non-BME respondents during telephone interviews may have helped to examine any differences in experience. The use of telephone interviews did not allow for the use of cues such as body language to seek further information. There is also less control over the interviewee's environment, meaning that disturbances may affect responses.
Conclusions
The main barriers to paramedic education for BME groups appear to be a lack of accessibility and understanding of information related to paramedic education, a lack of cultural understanding from non-BME staff members and students, and incidents that cause racial offence (unintentional or conscious racism). There also appear to be other factors which may act as barriers for other groups (e.g. issue of working hours for lone parents). However, many of the barriers emerging from this study may be applicable to both BME and non-BME groups. Further examination is needed in order to confirm these factors and suggest possible solutions to widen participation and prevent attrition in the paramedic services.