Paramedics must adapt to a number of working conditions and systems. Working shift patterns is one of the greatest adaptations required, and one that many struggle with throughout their careers (Clompus, 2014). The impacts of shift work on healthcare employees have been widely studied, from increased risk of cardiovascular disease, breast cancer and neurological problems to psychological impacts. The impact of paramedic shift work on family and home life is rarely studied and reported. It is not known if paramedics perform as well in marital and parental roles following a working shift, nor if the strain shift work puts on relationships is detrimental to the family system and child development. Bowen's family system theory states that families function as a system in which each person plays an independent and interdependent role (The Bowen Center for the Study of the Family, 2016); something that impacts one member will in some way impact all members of the family.
Anecdotally, paramedics speak of and warn about various negative impacts of shift work. While following similar broad themes such as missing important events, working weekends, going for long periods of time without seeing one's family and being ‘too fatigued to function’, each person experiences these effects differently. Personal circumstances, including the number of dependants and relationship status, greatly influence this interpretation. Conversely, some have expressed a preference for shift work as it may fit better with a partner's schedule or allow time to spend with families and friends (Kirby et al, 2016). Most ambulance trusts are struggling to recruit and retain the staff they need to meet rising demand (National Audit Office, 2017); investigation into how shift patterns may affect staff retention is warranted.
Methodology
The present literature search was conducted between January and March 2017 using the CINAHL, British Nursing Index (BNI), Medline, NHS Evidence and PubMed databases using the University of Brighton Online Library.
An initial scoping search was conducted using the key terms ‘shift work’, ‘paramedic/EMS/emergency medical services’ and ‘family’. From this, the key terms used in the searches in Table 1 were developed. Multiple searches were conducted using combinations of the terms. Owing to the lack of research into the effects of shift work on UK paramedics, a worldwide parameter was set and studies investigating other health professions were included (Aveyard, 2014). Inclusion and exclusion criteria were set as in Table 2.
| Search 1 | Search 2 | Search 3 |
|---|---|---|
| Paramedic or EMS or emergency medical service or ambulance or prehospital or pre hospital or pre-hospital or emergency | Paramedic or EMS or emergency medical service or ambulance or prehospital or pre hospital or pre-hospital or emergency | Paramedic or EMS or emergency medical service or ambulance or prehospital or pre hospital or pre-hospital or emergency |
| AND | AND | AND |
| Shift work or shiftwork or shift-work or shift pattern | Shift work or shiftwork or shift-work or shift pattern | Shift work or shiftwork or shift-work or shift pattern |
| AND | AND | AND |
| Family or family system or family theory | Family or family system or family theory | Family or family system or family theory |
| NOT | OR | AND |
| Nurs* or Doctor* or intern | Work-family fit or work family fit or work-family or work family | Emotion* or emotional labour or emotion processing or emotion work |
| NOT | NOT | |
| Nurs* or Doctor* or intern | Nurs* or Doctor* or intern |
| Inclusion | Exclusion |
|---|---|
| Published 2007–2017 | >10-year publication |
| Primary sources | Secondary sources |
| Published in English language | Non-English language or translated articles |
| Free to access | Cost to access |
| From peer-reviewed journals | |
| All study types | |
| Nurs* or Doctor* or intern |
The snowballing technique was employed to identify further research and the point of data saturation (LoBiondo-Wood and Haber, 2013). There were 22 papers found and used to inform the present review.
The framework developed by Caldwell et al (2005) was used to critique the qualitative and quantitative papers in parallel. The two main themes of the review are:
Emotional labour
‘If you focus…on your own emotions…you will have nightmares for years.’
Paramedics are regularly exposed to human suffering and its accompanying emotions (Williams, 2013a). Paramedics identify dealing with stressful incidents as the aspect of their shift work with the greatest impact on psychological health (Kirby et al, 2016). Boyle (2007) reported that the most emotionally demanding are not those incidents involving the greatest physical trauma but the non-urgent ones, owing to the uninterrupted exposure to social emotions. Emotional labour involves suppressing one's own immediate feelings and inducing others in order to sustain the socially expected outward expression of emotion (Seery et al, 2008; Filsted, 2010). This continuous cumulative pressure has been shown to lead to burnout, job dissatisfaction, and drug and alcohol abuse (Seery et al, 2008). Between shifts, the paramedic may bring the psychological impact home, making his or her family vulnerable to transmitted vicarious trauma (Regehr, 2005; Boyle, 2007).
Displays of emotion
Boyle (2007) identified an architecture that provides spaces in which different emotional rules apply for public and private performances of emotion. In order to process emotions, paramedics have been shown to use all three regions (Boyle, 2007). The on-stage performance involves face-to-face interaction with the public (Seery et al, 2008), frequently exhibited through surface acting (Boyle, 2007). Debriefing in the vehicle or at the station—the off-stage arena—has been identified as an important coping mechanism employed by paramedics, providing a space to react ‘unprofessionally’ (Steen et al, 1997; Filsted, 2010; Williams, 2013b). However, this debrief often includes only technical elements and is too brief to process emotions (Boyle, 2007). Recognised as the primary mediator of emotional strain at work, the back stage display occurs at the home with family and friends (Regehr, 2005; Boyle, 2007; Williams, 2013b; Clompus, 2014).
The male coping culture
The norms expected from an employee are developed from the overarching organisational culture (Seery et al, 2008). The assumption of the ‘hero status’ (Boyle, 2007: 60), that paramedics are above emotions (Slabbert, 2017), comes from the traditional, historical masculine culture of paramedic practice (Menzies, 1960; Steen et al, 1997; Boyle, 2007; Filsted, 2010; Williams, 2013a; Clompus, 2014). This dictates an emotional culture within the ambulance service of showing minimal emotion, both as paramedics and working in the ‘stiff upper lip’ British culture (Sooke, 2016). The current paper argues for a cultural change to reflect an increased proportion of women and ethnic minority paramedics entering the profession.
Family views
Families suggest that the emotional ‘hardening’ paramedics develop is what they bring home from shift work (Regehr, 2005). Described as an ‘armour’ (Clompus, 2014: 146) and a ‘wall’ (Filsted, 2010: 377), the distressed paramedic is seen to shut down emotionally and this transfers to the home environment (Clompus, 2014). Others suggest that, over their career, the paramedic becomes mwore adept at making the emotional transition from work to home (Clompus, 2014).
If emotions remain unprocessed, however, the paramedic is susceptible to projecting this onto family in outbursts of anger and hostility (Regehr, 2005; Clompus, 2014). Families experience the paramedic's detachment, describing how they ‘stopped doing everything’ (Regehr, 2005: 106) and refuse to share their feelings (Williams, 2013b), as well as suffering from the consequences of the paramedic's compassion fatigue (Slabbert, 2017). Therefore, some families avoid highly emotional interactions, whereas others have learned to give their paramedic time and space alone (Regehr, 2005; Roth and Moore, 2009).
Discussion
Historically known as ‘ambulance men’, the paramedic profession is today, as it has always been, male-dominated. This may have led to paramedics priding themselves on being able to cope with anything; this attitude, however, has been linked to severe mental health problems such as post-traumatic stress disorder (PTSD), depression and substance misuse (Mildenhall, 2012).
With the increasing number of female paramedics in the UK, the ratio of male:female paramedics is becoming more even, from 3.33:1 in 2006 to 1.64:1 in 2017 (Health and Care Professions Council (HCPC), 2017). These data beg the question whether the increase in female workforce is changing the culture or whether women are simply fitting into an established male culture. The need for change in this male culture is evident, not only to protect paramedics, from potentially life-threatening mental health issues, but also their families and relationships.
One way to tackle this is through education of both paramedics and their families. This is starting to filter into organisations through the university programmes with training in debriefing, recognising emotional struggle and Mental Health First Aid courses. Additionally, trauma risk management (TRiM) programmes are being introduced into the UK bluelight services following success in the military (Greenberg et al, 2008). However, TRiM is designed to be used after major incidents, not the incidents that cause the most emotional distress to paramedics. The need to develop a TRiM-like programme for use with cumulative distress from non-urgent incidents is evident. A further way that this might be addressed is by the introduction of professional clinical supervision as is used in nursing, midwifery and other health professions. Table 3 also identifies some useful resources that a paramedic can access directly.
| MIND Blue Light Programme | https://www.mind.org.uk/news-campaigns/campaigns/bluelight/ |
| The Ambulance Service Charity | http://www.theasc.org.uk/ |
| College of Paramedics: Paramedic Mental Health and Wellbeing Steering Group | https://www.collegeofparamedics.co.uk/college-governance/structure/paramedic-mental-health-and-wellbeing-steering-group |
| Our Blue Light | https://ourbluelight.com/ |
| Find out what your employer offers and what is available locally. |
|
Ambulance services have implemented these measures to reduce the effects emotional work has on the home system, by facilitating emotion processing at work. Paramedics will still discuss work with their families even though they may have processed the incident. This will put the family at risk of emotional distress and families should also be offered education in emotional labour and identifying symptoms in themselves. In the UK, support for paramedic families is available from The Ambulance Staff Charity and MIND, but these are reactive—not proactive—support measures.
Work-family fit
‘He has missed a lot of…different activities; even any kind of event is a struggle for him to be there.’
In a society that operates on a 9-to-5 schedule, life for families of paramedics can often be stressful. The family system is not immune to the impact of the long and unpredictable non-standard working hours of paramedic shift work. Work-family fit (WFF) examines family stress related to employment and how adaptation relies on finding a balance between work and family (Roth and Moore, 2009). Without this balance, the resulting stress and imbalance can manifest in disruption to physical, mental and social wellbeing (Roth and Moore, 2009).
Work-family conflict
The majority of the current literature investigates WFF by examining the role of work-family conflict (WFC). WFC is the person's subjective experience of work impacting their family life and how successful they are in balancing work and family roles (Tuttle and Garr, 2012). Balancing work and family domains can be an additional source of stress, on top of those arising from the nature of paramedic work. Time and energy constraints and psychological carryover from one domain to the other lead to increased WFC, and can also give rise to family-work conflict (FWC), the impact of family life on work (Tuttle and Garr, 2012). Not only is shift work positively correlated with WFC, but characteristics of paramedic shift work such as working weekends, high weekly hours and emotional labour have also consistently been found to be uniquely associated with WFC (Perry-Jenkins et al, 2007; Barnes-Farrell et al, 2008; Tuttle and Garr, 2012). Higher levels of depressive symptoms, work overload, and rotating shift schedules—all present in paramedics (Patterson et al, 2010)—lead to higher WFC (Perry-Jenkins et al, 2007). There are similar findings across the Police and Fire and Rescue services (Garbarino et al, 2013; Griffin and Sun, 2018; Smith et al, 2018).
Work-family enrichment (WFE)
Tuttle and Garr (2012) argue however that the effects of shift work on the family system may not be as negative as previously thought, owing to the mediating effect of WFE. WFE theory suggests that resources and experiences gained in one domain can improve performance in another. For example, paramedics typically enjoy their work and feel that they are making a difference to their patients; this, together with family pride in their paramedic work, contributes to WFE (Roth et al, 2008). A perception of greater WFE has been shown to improve job satisfaction, reducing one factor contributing to WFC (McNall et al, 2010). Increased perceptions of WFE are correlated with reduced staff turnover intention (McNall et al, 2010). This is an important finding for recruitment and retention (NHS Pay Review Body, 2015).
Social life
Roth and Moore (2009) investigated the impact of working in the ambulance service on WFF and the family system. Of the 12 participants, 11 indicated that holiday and social activities are disrupted by shift work. A rotating schedule and afternoon-evening shifts were described as the most problematic, with arranging holiday being particularly stressful. These findings are consistent with other studies where paramedics describe social isolation due to unsocial hours (Roth et al, 2008; Kirby et al, 2016). More recently, however, paramedics' shift hours have been viewed in a positive light, providing more days off to partake in social events and enjoying activities outside of the constraints of 9-to-5 work (Kirby et al, 2016). The individual's personal circumstances and degree of social flexibility therefore greatly influence their perception of the impact of shift work.
Family and parental role
Roth and Moore (2009) also identify that paramedic shift work can alter and negatively impact marital and parental roles (Perry-Jenkins et al, 2007). Negative impacts on intimacy in relationships through fatigue (Regehr, 2005) and additional pressure on partners (Roth and Moore, 2009), as well as increased marital dissatisfaction and conflict (Roth et al, 2008) may lead to dysfunctional and strained relationships.
Families where at least one parent works non-standard hours report difficulties in arranging childcare, often turning to close family for help (Kirby et al, 2016). Barnett and Gareis (2007) suggest that some parents may choose shift work to fit around their partner's hours, requiring less formal childcare and thereby reducing costs. Strazdins et al (2006) found that when a parent works shifts, families find it hard to maintain rituals and routines, creating implications which negatively impact the child's wellbeing (Regehr, 2005). Strazdins et al (2006) also found that stress from shift work alters the worker's mood and energy which, in turn, increases hostile and ineffective parenting, leading to parental distress and depression impacting the time spent with their child. These factors were all found to be associated with abnormalities in children's behaviour and cognitive development (Strazdins et al, 2006).
Conversely, others argue that shift work allows flexibility in the family role, even suggesting that it is ‘family friendly’ (Tuttle and Garr, 2012). Roth et al (2008) found many families felt that their paramedic was able to share in household chores and parenting roles, believing that shift work does not have a negative effect at home. Paramedics continue, however, to express distress at seeing the effects of their working schedule on their family, reporting feelings of guilt (Roth et al, 2008). The degree of compromise and flexibility the paramedic has in a parental role dictates the levels of marital strain, parental role compromise and WFC experienced.
Flexible work arrangements
McNall et al (2010) also investigated the effect of flexible work arrangements (FWA) on work outcomes and in balancing work-family life. FWA increased the perception of control over work and family matters, thereby reducing WFC and absenteeism, while increasing performance and job satisfaction (McNall et al, 2010). Subsequently, FWA have also been found to be positively related to WFE and negatively to staff turnover intentions (Tuttle and Garr, 2012).
Coping mechanisms
Roth and Moore (2009) discovered a number of coping mechanisms employed by paramedics and their families to adapt to the impacts of shift work on WFF. The majority of families described social support from close friends and family. Family members also stress the importance of developing and cultivating their own interests and hobbies (Regehr, 2005), maintaining their individual identity so as not to become an ‘EMS widow’ (Roth and Moore, 2009: 465). Flexibility in childcare, household chores, family roles, and social expectations are other strategies employed by many paramedic families (Roth and Moore, 2009). Without this compromise, families would not be able to cope with the challenges of shift work.
The literature to date shows a variety of perspectives of both the positive and negative effects of working shifts as a paramedic. Overall, despite necessary compromises, families appear to be able to adapt and cope with the strains and stresses of having a paramedic working unusual hours (Roth and Moore, 2009).
Discussion
Barnes-Farrell et al (2008) note the importance of understanding the multifaceted nature of shift work. As most of the current literature examining the WFF impacts of shift work acknowledges, only a single aspect of shift work—the breadth and scope of current knowledge—is limited.
Although marital relationships, childcare, family roles, and social activities are important when considering the WFF of paramedic shift work, it is suggested that they can all be mediated by FWA (McNall et al, 2010). Many of the factors that contribute to WFC such as inflexible schedules, rotating schedules, and working weekends can also be reduced by FWA (Perry-Jenkins et al, 2007; Tuttle and Garr, 2012). Moreover, WFE can also be enhanced by FWA as proposed by social exchange theory (Blau, 1964).
It seems conceptually challenging to employ FWA in the ambulance service, requiring as it does staffing round-the-clock. If staff were offered flexibility in their schedules it might be difficult to cover the unsocial hours. However, the North East Ambulance Service (NEAS) in the UK has set out to ‘[improve] working lives through employee friendly policies and procedures and flexible working practices’ (NEAS, 2011). Changing working hours and weeks provides employees with the opportunity to alter the number of days worked per week. It is unclear how this affects staff not on the programme, how their hours will change during the school holidays and if such staff absence increases the demand and strain on remaining staff. Implemented for all employees of the Trust, some of the family-friendly aspects of the policies are not, however, available to frontline paramedics. West Midlands Ambulance Services (WMAS) in the UK has also implemented a promising Flexible Working Policy, but this too is available only to administrative and clerical staff (WMAS, 2017).
Introducing FWA will not immediately solve the problem of WFC: poor implementation can have the opposite effect (Ryan and Kossek, 2008). With all organisational changes, there will be opposition, and implementation must be carefully planned to overcome this. Particularly relevant to work-life policies, perceptions that those using the policy gain an unfair benefit at their coworkers' expense must be avoided (Ryan and Kossek, 2008). FWA policies seen to benefit all staff will also aid recruitment, presenting a service invested in caring for staff, having recognised the difficulties in balancing work and family life (NEAS, 2011).
Limitations
The current literature review used a systematic approach: the original search was conducted as part of the author's undergraduate research, with a comprehensive review beyond its scope. This is an area of paramedic practice infrequently studied; consequently, many of the papers reviewed are not specifically investigating paramedics but other health professionals. Most of the literature reviewed is not UK based and, although shift work is universal in ambulance services, other factors such as workload and shift patterns differ. Small samples combined with the often personal and sensitive nature of the investigations may lead to biased results, underreporting and misrepresentation of true attitudes and perceptions (Polit and Beck, 2011; Parahoo, 2014).
Conclusion
Families of paramedics feel the impacts of shift work in numerous ways (Regehr, 2005; Roth and Moore, 2009). Changes are required in the organisational culture, from one that denigrates staff for showing emotions and for struggling to balance their home life with work, to one that improves paramedics' experience at work and therefore their home life as well. Investment in education programmes for families on how to enable emotional processing and on the risks this carries will improve the picture for families of paramedics.
FWA is an area of organisational reform that could greatly improve job satisfaction, staff retention and recruitment, and ultimately family life. Further research into this area of paramedic practice is needed to better understand the impacts of shift work on the family, and the influence this has on career decisions, as well as on the health and wellbeing of the paramedic and their family.