Undertaken by a team of sociology researchers from the University of Manchester, this ethnographic study deploys a variety of qualitative methods to elicit its findings. Conducted between 2009 and 2010, it includes field observations conducted with road crews, call-handlers and dispatchers, and semi-structured interviews with managers and control staff. The researchers blend observations with comments made by staff, drawing parallels with a similar study carried out in the US by Donald L Metz in 1981.
Behind the provocative title is a novel and welcome piece of work, astute in its assertions and at times uncomfortably revealing. It questions how quickly the paramedic profession really is advancing, something officially sanctioned paramedic literature would have you believe is undeniable. It also questions the autonomy of paramedics in light of the managerial and organisational constraints put upon them.
The paper argues that formal professionalisation—pursued by bodies such as the College of Paramedics—has thus far had little impact on the paramedic experience at street level. The authors suggest this is linked to the as-yet limited influence the College holds with ambulance service employers, who ultimately dictate job jurisdiction and work content. As a result, front-line staff maintain a traditional blue-collar status in an attempt to control their conditions of labour.
The term ‘blue-collar professionalism’ was originally used in Metz’ ethnography of ambulance work to describe the hybrid status of ambulance personnel in the USA. The authors suggest paramedics and road crews in the UK continue to identify with this image, enacting blue-collar forms of work as a method of resisting overbearing micro-management. McCann et al cite sickness-related absence, manipulation of timings and end-of-shift ‘go-slows’ as examples.
What may come as a surprise is the assertion that paramedics enjoy only superficial levels of formal autonomy. The authors comment that paramedics work in a universally low-trust environment that breeds anxiety over clinical errors and fear of litigation and complaint. For this reason, ambulance staff are self-limiting in their actions. This can also be seen at an organisational level: guidelines are largely written by other medical professionals, clinical and operational decisions are scrutinised by managers, and paramedics are regulated by an external body. The authors state that, unlike other professions, ambulance staff cannot resist such top-down control.
The authors admit that their study has limitations. For instance, the evidence is based on just one Trust. Nevertheless, any UK ambulance personnel would be able to identify with the examples they reference. Another drawback identified is the lack of interviews with representatives from the College of Paramedics.
Perhaps the paper's greatest benefit to the discerning paramedic is the insight it gives on the professionalisation project—that of an objective outsider looking in. It places the paramedic profession in a historical context and draws comparisons with similar professions that are in the process of endeavouring to shed their previous occupational status. The study should be seen more as a snapshot of the profession than anything more substantial.
As for the future, the forecast looks gloomy: work intensification is increasing whilst public purse strings are tightening. In some Trusts, long-established skills have been prohibited and part of the workforce is de-skilling—witness the increasing replacement of emergency medical technicians with support staff whose roles are clinically more limited.
But there is some hope. The paper suggests that the profession's best chance of attaining ‘occupational closure’ and work autonomy lies in greater organisational control: ultimately, a stronger College of Paramedics, something that must surely be welcome.