Influences on ambulance staff’s understandings and safeguarding of ethical values

Study setting

In Sweden, 59 neighborhoods have been defined by the Police Authority as having criminality that impacts the local community as well as having socioeconomic deprivation. Since 2015, these neighborhoods have been published in a publicly available list involving approximately 5% of the Swedish population (i.e., about 500 000 persons). ²² The neighborhoods included in the list vary in size and demographic characteristics, but in general they have a lower socioeconomic status and a larger proportion of persons born in another country or with parents born in another country than the rest of Sweden. ²³ These neighborhoods have been identified as exposed to stigmatization, and the publication of the Police Authority’s list may contribute to this with negative consequences such as stereotyping, social exclusion, and discrimination against its residents.^24,25

This study was conducted within the Swedish AS in two ambulance districts that both have neighborhoods included in the Police Authority list. ²² The ambulance districts are located in different parts of Sweden that together have about 80 000 assignments/year. The Swedish AS is regulated by the National Board of Health and Welfare ²⁶ and is part of the Swedish welfare system financed by income tax, but some districts charge a fee for the service. The state regions provide the AS and are responsible for the ambulance staff’s competence, their work environment, and that the ambulance care complies with regulations. ²⁷ The AS is responsible for emergency care in a prehospital setting. This includes advanced assessment, treatment, and triage, which can result in transport to the emergency department, to definitive care, to another health care facility or non-conveyance. The AS also collaborates with the police, the fire department, and other health care facilities when needed. ²⁷

The Swedish ambulance assignments are distributed by the nationwide Emergency Medical Communication Center (EMCC), which replies to emergency calls, prioritizes assignments, and collaborates with the police and fire department in dispatching services. In addition, several regions have their own communication center that distributes ambulance assignments when the EMCC has identified the call as a health care matter. When assignments are allocated to an ambulance unit, they typically contain information about the patient, location, and reason for contact. ²⁸ Ambulance units are advanced life support units that usually consist of two staff members where one must be licensed to administer drugs, which most commonly implies a Registered Nurse (RN). In Sweden, RNs have a 3-year university education with a bachelor’s degree in nursing science and may also have completed a 1-year specialist training leading to a master’s degree in nursing science. ²⁶ One of the staff members can also be an Emergency Medical Technician (EMT). EMTs have a high school diploma or 1 year of higher vocational training. ²⁸ Further details about the study setting are available elsewhere. ¹¹

Participants and data collection

In a previous study exploring ambulance staff’s understandings of health care encounters with persons living in stigmatized neighborhoods, ¹¹ additional rich narratives emerged about influences that participants viewed as forming their understandings. Recognizing that knowledge about such influences is essential for a more comprehensive understanding of these encounters, we reanalyzed the full dataset with a new aim. Thereby, this study shifts the focus from examining how ambulance staff understands these encounters to exploring what influences those understandings, highlighting the underlying mechanisms that shape, rather than express, their understandings. The interview guide thus did not explicitly involve questions about what influenced their understandings (Table 1), but such narratives emerged spontaneously or in response to follow-up questions during the interviews (Table 2).

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Table 1.

Interview guide.

Interview guide
How did you perceive the health care encounter with this person?
What did you perceive could provide support during the health care encounter?
What did you perceive could cause problems or difficulties during the health care encounter?
Do you want to add something?
Example follow-up questions
Can you develop that? How do you mean? You said… can you tell me more about that?

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Table 2.

Examples of narration that include influences on how ambulance staff understand health care encounters with persons living in stigmatized neighborhoods.

Participant	21	19	20
Questions	You told me before that you get information via the media. How do you think that can affect the health care encounter?	You also talked about a group analysis in the staff room, can you describe?	You also told me when you saw the address in the alarm text [from the EMCC], before you got to the patient you started thinking about things that had happened before. Can you tell me more about this?
Answers (abbreviated)	Yes, but it builds, it forms our prejudices, definitely… Of course it’s media angles, of course they highlight all of this. They never show the man with a doctor’s ID… the media describes the violence and the shootings… when you hear about these crimes, it is once again the young, foreign-born man, in a disadvantage area who has committed them. You’re probably naive or stupid if you don’t get any prejudices about it or grow some kind of protection mechanism within you to be cautious.	It is a learning that is not always a healthy learning, learning also includes the attitude, …it is not always that those who are the loudest lecturers in the staff room are the sharpest or do the best work, but they still become role models for many who believe that this is the truth, this is how we should act, this is how we should see and who maybe even don’t always think that much or make their own observations.	Yes, last week, there were PMs distributed, or whatever they are called, of recent events and I remember the police had meetings with us then, about just this area… we talked about it on a daily basis, at every shift, at the beginning of every shift, we talked about this particular area …when you see that you are going there [in the received assignment] …it’s not like you want to go there exactly, I have to admit that, I would rather escape.

Purposeful sampling was used, and the inclusion criterion was to have worked a minimum of 2 years in the AS to ensure sufficient experience. Unit managers or the first author gave information about the study at workplace meetings. Interest in participation was collected by the unit managers and the first author asked about consent to participate in the study. The study included 27 ambulance staff (7 RNs, 15 RNs with specialist training, and 5 EMTs; median age, 42; 12 women; median years in AS, 7). Data were collected through individual semi-structured interviews. Definitions of stigmatized neighborhoods and health care encounters were provided, and the interviews followed an interview guide where participants were encouraged to talk freely about a health care encounter with a person living in a stigmatized neighborhood. Interviews were conducted through face-to-face meetings (n = 7), telephone (n = 3), or online (n = 17) and then transcribed verbatim. Detailed descriptions of the sample, participants, and data collection are available elsewhere. ¹¹

Data analysis

The data were analyzed by following Krippendorff’s five steps of content analysis ²¹ supported by the NVivo software program (version 14, 1533) in steps two and three: 1. (Unitizing) Transcribed interviews were selected as data material since all authors considered them appropriate relative to the aim of this study. 2. (Sampling) The complete transcripts were read by the first and last authors. Content that was relevant to the aim was extracted by the first author and then jointly discussed with all authors. 3. (Coding) The extracted sections were broken down into smaller text units and labeled with a code describing the content, resulting in 408 codes. Similar codes were grouped into categories. All text units, codes, and categories were then read by the last author before the first and last authors discussed and reviewed the content. Units, codes, and categories were then reviewed by all authors and discussed jointly. 4. (Data languages) The first and last authors text-closed the categories content, followed by joint discussions with all the authors and revision. 5. (Analytical constructs) The first author then reanalyzed the data to find meanings of the categories content and expanded the category descriptions based on these findings. This was then presented to all authors who discussed it and revised it together.

Ethical considerations

The study was approved by the Swedish Ethical Review Authority (Approval No. 2021-06744-01) and conducted in accordance with the Declaration of Helsinki. All participants received oral and written information about authors’ professions, the aim of the study as well as the procedure and that they could withdraw at any time. Written informed consent was obtained from all participants before the interviews, which were audio-recorded. The digital sound recordings were transcribed and coded, password-protected, and saved on an encrypted university server, and transcriptions were pseudonymized.

Individual values

Cultural traditions, upbringing, and social standards were described by the ambulance staff as generating individual values. These values were viewed as forming personal qualities involving perspectives on humanity, helpfulness, and openness. These individual values were described as either reinforcing or challenging personal as well as broader understandings among themselves, at their workplace or in society as a whole.

“I think it’s just how you are as a person, your view of people and how you treat people and how you were brought up. I don’t think any nursing science or anything like that can help you encounter people well if you, like, if you’re not like that as a human being yourself.” (Participant 13)

The ability to be aware of different understandings and to critically appraise them was described as a necessity to avoid being influenced by preconceived notions when encountering patients. The ambulance staff described that acknowledging and questioning understandings about specific neighborhoods, ethnicities, or cultures generates a resistance toward the temptation to categorize patients based on stereotypes. This ability was viewed as being cultivated through relationships where understandings are challenged, leading to the development of new insights.

Colleagues

When an ambulance unit receives an assignment, colleagues were described as jointly expressing opinions about the causes of symptoms and what type of care was required. This collective meaning-making process was viewed as forming a shared understanding which shapes expectations and conclusions before encountering the patient. This was viewed as shaping a general understanding of how to approach persons living in specific neighborhoods despite differences in the assignment or in needs. This generalizing approach potentially hinders the ambulance staff’s ability to recognize and respond to unique needs but also forcing them to muster enough courage to develop their own approach.

“If he is super sure and says like this: I promise you this, then it colors my picture of the situation, and you learn from your experienced colleagues. I then think that of course he has seen this sort of thing, he certainly knows what he is talking about! And you are probably influenced by your colleagues, especially if you are new. If the experienced colleagues behave like this and spread these stereotypes, then it forms some kind of culture in the workplace that is easily transferred to new recruits.” (Participant 14)

Colleagues’ stories about their previous experiences were tolerated even when exaggerated. Stories involving patients living in specific neighborhoods were not described in terms of individual variations but through generalized assumptions tied to specific ethnicities or cultures. These stories were often considered harsh as well as judgmental, contributing to an “us-and-them” where the patient was viewed as fundamentally different or even inferior. These stories were viewed as forming a culture with a collective understanding and a resistance to alternative viewpoints, influencing how patients are understood. This made it difficult to express one’s own perspective when it conflicted with the prevailing understanding and was seen as generating a struggle to avoid being influenced by general understandings occurring in the workplace.

Associated organizations

The ambulance staff’s understanding of persons living in specific neighborhoods was viewed as influenced by the perceived attitudes of staff within the EMCC and the emergency department. This influence was viewed as reinforcing existing preconceptions or creating an internal struggle, where one had to actively resist being blinded by stereotypes that were strengthened through these shared attitudes. The ambulance staff described how this influence could shape preconceived notions about patients’ needs and how they should be approached.

“Sometimes in the alarm text, the EMCC staffs´ perceptions shine through. Even if they write briefly and with words like… it often shines through if they have had a conversation that has been…difficult due to language barriers and it may have been noisy in the background and maybe there was also irritation. You can almost see it from the alarm text. And then, somewhere, something happens in your brain and in your body, and you also prepare for that.” (Participant 6)

The categorization of neighborhoods as being “high-risk” was viewed as influenced by official lists of residential areas defined by the Polis Authority, alongside information about local areas gained through collaborations with local law enforcement. This contributed to a preemptive understanding and to a narrative of danger associated with both the place and its residents, which framed encounters through a lens of suspicion. This influence was viewed as shaping a distance between the ambulance staff who must protect themselves and the patient who is understood as a potential source of risk. The distance reduced persons, living in neighborhoods seen as high risk, to be understood as representatives of a problematic area, overshadowing their unique needs.

Societal information

Information received through media or community hearsay was described as shaping broad, generalized understandings not only of specific neighborhoods but also of persons associated with specific ethnicities or cultures. These narratives were often considered problem-focused, frequently linking issues to persons with a foreign background. This was viewed as reinforcing broader stereotypes linked to ethnicities or cultures, contributing to a perception of “us-and-them” that extended beyond specific neighborhoods.

“When you hear about these crimes, it is once again the young, foreign-born man, in a disadvantaged area who has committed them. You’re probably naive or stupid if you don’t get any prejudices about it or grow some kind of protection mechanism within you to be cautious.” (Participant 21)

The understanding of threats against ambulance staff during assignments was viewed as influenced by media and community narratives about specific neighborhoods. These narratives, often centered around crime or violence, were considered influential regardless of whether the incidents involved the AS or occurred locally or elsewhere in Sweden. The spread of such narratives was seen as contributing to a generalized understanding of specific neighborhoods, framing them as inherently dangerous and forming a distancing process from the persons living there. However, when personal understanding conflicted with these narratives, the ambulance staff expressed resistance. They described understandings of injustice toward those targeted by these narratives as well as a responsibility to avoid being blinded by these influences.

Professional experiences

The ambulance staff described a tendency to form generalized understandings based on their professional experiences with patients in specific neighborhoods. This influence was seen as potentially hindering their ability to adapt care to unique needs, raising a risk of making assumptions when providing care. The ambulance staff noted that due to this tendency to form generalized understandings, they had to consciously work harder to prevent them from influencing their approach in the encounter with the patient.

“All these encounters you’ve had, some you completely forget but most of them you still kind of recall a little: oh, I have been in that building before, doesn’t an old lady live there? If you’ve been there before and you get that address it’s like: isn’t that where he or she lives, do you remember when we were there?… And it is similar when it comes to these neighborhoods, but the difference is that you generalize a bit more… It is a special neighborhood, and they are sweeping generalizations.” (Participant 21)

The influencing professional experience involved health care encounters in neighborhoods considered generally singled out as different, as well as encounters in other residential areas where the patients were associated with specific characteristics (e.g., ethnicities, cultures, drug use, and violence). This influence was formed by interactions with “those” perceived as unfamiliar and different from oneself. This was viewed as resulting in an understanding where the ambulance staff and the person in need of care were seen as belonging to separate groups in society with little in common. However, the ambulance staff also described understandings of recognition or togetherness despite differences in backgrounds. Such understandings were viewed as influenced by the own capability to see beyond generalizations and stereotypes, which was facilitated by reflection of own viewpoints as well as external influences.

Management

The lack of management focus on reflection after assignments was viewed as preventing awareness of prejudices as well as behaviors. This was seen as reinforcing unchallenged understandings, where assumptions were accepted as truths without critical reflection. This was described as a process where unchallenged viewpoints shape how ambulance staff understand and interacted with patients considered as not belonging to their own group. When working with a colleague who showed interest in reflecting on understandings and experiences, this process was instead transformative and enhanced the ability to gain new insights.

“To be given the opportunity [by the management] to see things in different ways and discuss a thing and talk about it… just like I do now, I see things in a different way. Meanwhile, if I hadn’t talked about it, it would have just been the experience and the perception that I had right after and it would have remained the same, as it were. And it is obvious that it would have affected a similar health care encounter.” (Participant 6)

The management’s strong emphasis on safety strategies was seen as influencing a collective understanding of threats to personal safety when encountering patients in specific neighborhoods. This focus on safety contributed to an understanding of specific neighborhoods as inherently dangerous and that ambulance staff should maintain a distance from those living there for their own protection. The distance was seen as hindering care from being responsive toward patients’ needs. The ambulance staff also described that such distance formed an understanding of guilt as they struggled with the inability to connect on a human level or provide empathetic care.