Abstract
BACKGROUND:
Several studies show that professionals in the two main models of pre-hospital care (Franco-German (FG) and Anglo-American (AA)) are exposed to different psychosocial risk factors, with consequences such as burnout syndrome. Few studies provide information on protective factors, nor are there any results on risk/protective factors from the perspective of professionals and comparing both models (FG and AA).
OBJECTIVE:
From the perspective of medical transport (MT) professionals, we aimed to identify the risk/protective factors that may be involved in occupational burnout syndrome (OBS), comparing Franco-German (FG) and Anglo-American (AA) pre-hospital care models, as well as emergency (EMT) and non-emergency (non-EMT) services.
METHOD:
This was a qualitative research, through 12 semi-structured, in-depth interviews with participants chosen through intentional and snowball sampling. Content analysis and coding was carried out based on Bronfenbrenner’s ecological model and supported by the N-VIVO computer program.
RESULTS:
Our results illustrate the multi-causal nature of OBS, with risk/protective factors interacting at different levels of the ecological model. Among the data found at the different levels, some of the risk factors provoking OBS most commonly cited by professionals from both models are: work overload, work schedules, the coordinating centre, relationships with managers, the lack of work-life balance, the institutional model, the privatization of companies and the bureaucratization of management. The most cited factors acting as protectors include the stress involved in the emergency services, relationships with colleagues, relationships with other professionals or users, and social recognition.
DISCUSSION:
In general, we conclude that there are more similarities than differences in terms of how the workers in each model perceive the risk/protective factors.
Keywords
Introduction
Medical transport (MT) involves transferring sick or injured people by ambulance from any location to a health facility or from one health facility to another. A significant increase in demand for MT in recent years [1–5], as well as adaptations made in response to demographic, social, political and economic changes, have contributed to an uneven development of the organizational models of medical transport [6–8] both globally and between states or regions of the same country [8, 9].
The literature on the subject groups pre-hospital assistance into two main models: the Anglo-American model and the Franco-German (or Franco-European) model [9, 10], although each model has undergone certain modifications, according to the needs of each country or region. The Anglo-American (AA) model, commonly known as “taking the patient to the hospital,” has been adopted in countries such as the United States, Canada, Japan, South Africa and Australia. Generally, in this model, the teams consist of emergency medical technicians, or paramedics, trained to administer basic, intermediate or advanced life support techniques, according to each local model. The Franco-German (FG) model, known as “taking the hospital to the patient,” is used in countries such as Germany, France, Spain, Portugal, Malta and Austria. In this model, basic life support techniques are carried out by the team of medical transport professionals, with medical staff and/or nurses being added to the teams when intermediate or advanced life support is required, depending on the cases and countries [9, 10]. Consequently, with regard to medical transport management (MT), the majority of countries using the FG model differentiate between emergency medical transport (EMT) and non-emergency medical transport (non-EMT) [8], while there is no explicit differentiation of these services in countries that have adopted the AA model. By EMT, we mean the transfer of sick or injured people in vehicles that are specially prepared for situations that involve risk of death or irreparable damage to health, while non-EMT involves exceptional displacement of sick or injured people who for clinical reasons cannot use ordinary transportation.
The evolution of MT and changes in the sector have also prompted interest in the health of MT professionals [11], leading to studies on a range of physical, ergonomic, biological and psychosocial risk factors. In this work, we focus on the psychosocial health of MT professionals and, while several studies have addressed this issue in terms of the prevalence of risk factors and the influence they have on the health of these workers, there is little research into any protective factors that may have a positive impact on health. Similarly, there are few studies into any differences that may exist in terms of exposure to psychosocial risk/protective factors between EMT and non-EMT workers or between MT personnel in the two different models of pre-hospital care described above.
With regard to risk factors, most studies into psychosocial health among MT professionals around the world include analysis of the following variables: stress [11, 12], post-traumatic stress [13, 14] and occupational burnout syndrome (OBS) [11, 16]. Data on occupational burnout syndrome (OBS) is available for countries using Anglo-American pre-hospital models [17] as well as those with the Franco-German system [12], although the results are inconclusive. Some studies [15] say there is a slightly higher probability of OBS among MT workers than there is among the active population in other sectors, while others indicate a slightly lower probability [18]. As for protective health factors, the existing research in the MT sector highlights the sense of coherence (SOC) [19, 20] and subjective well-being (SWB) [21]. Among the few existing studies that have looked into the differences in exposure to factors of psychosocial risk and protection among EMT and non-EMT staff and the prevalence of OBS in the two groups, a recent study by Navarro, González and Villar [22] revealed results on aspects such as working conditions, sense of coherence, subjective well-being and OBS that were less favourable for non-EMT professionals than for EMT professionals.
Although there are numerous studies on the prevalence of OBS risk factors in the MT sector and, to a lesser extent, on protective factors, very little of this research reveals how the professionals themselves feel about the causes that contribute to stress in their work environment [23–26]; consequently, their views on the issue in terms of working on EMT ambulance crews compared to non-EMT crews are not known either. Qualitative research, using techniques that gather data on individual experiences and practices, has been shown to provide a deeper understanding of a problem under study [27]. However, there are very few investigations that have used this methodology in the area that concerns us here.
The objective of this study is to examine what MT professionals believe to be the determining factors involved in their psychosocial health, or more specifically, the causes that influence the appearance of OBS and the possible factors that help to prevent it. The aim is to obtain this information from people working under the Anglo-American model and from others working under a Franco-German MT management model and seeing if there are any differences in perceptions between the two groups. As the FG model is further subdivided into EMT and non-EMT teams, we will also try to discover any differences in perception between those involved in EMT tasks and those involved in non-EMT services. This is, we believe, a novel contribution to the literature.
Occupational burnout syndrome (OBS) from the perspective of Bronfenbrenner’s ecological theory
Maslach and Jackson [28] described burnout as a three-dimensional syndrome characterized by emotional exhaustion (feeling emotionally empty, exhausted when trying to meet demands that feel overwhelming), depersonalisation (showing insensitivity to the work being done and to the users of the service; treating them or addressing them in a cynical and dehumanized way), and reduced personal accomplishment (strong feelings of incompetence and failure).
The consequences of burnout are negative for the staff, the institutions they work for, and the clients or users of the services they provide [29, 30]. The risk of suffering burnout was, in the initial theoretical models, attributed to the workers themselves and their personality traits. Other explanatory variables have since been incorporated –such as an individual’s interaction with the organizational and social environment [31] in line with the Bronfenbrenner’s ecological systems theory [32] which explains human behavioural development and change in terms of the interaction between the person and their environment.
Specifically, Bronfenbrenner [32] conceives of this interaction in the form of a series of systems or structures, each one nested within the next like a set of Russian dolls, all of which are in constant interaction. The innermost system, which he calls the microsystem, corresponds to aspects of the individual’s most immediate field of interaction, such as home, school, or work, among others. Next comes the mesosystem which comprises the set of interconnections that occur between the various microsystems of which the individual is a part. Then there is the exosystem: these include environments can affect the individual despite their not being present. One example would be the interactions that occur within other microsystems involving other people from their environment and which may still have an effect upon their lives. Another example, among others, would involve institutional or local government regulations. Finally, at a fourth level, and within which the other three levels interact, is the macrosystem, which characterises the sociohistorical moment and culture of each social environment [32]. Although Bronfenbrenner’s original model has undergone a number of modifications over the years [33, 34], the holistic nature of the approach and the fact that it is widely used as an explanatory frame of reference in the field of health makes it a useful analytical tool for studying complex, multifactorial phenomena such as OBS. However, we must bear in mind that one of its main limitations is the very complexity involved in dealing with any phenomenon that attempts to consider all the possible interconnections between the different agents and systems at play.
This article tackles the complexity of burnout from the perspective of Bronfenbrenner’s initial ecological model [32], by considering the dimensions of OBS as a result of the worker’s interactions –at various levels –with his or her social and working environments. To this end, the influence of various risk/protective factors at each level of the ecological model is analyzed, including some theoretical frameworks that have been widely verified in the field of organizational studies that complement these different levels of analysis. For instance, at the microsystem level, we include the theory on the meaning of work [35]; at the exosystem level, we include the institutional theory [36] and at the macrosystem level, the theory of social recognition [37].
At the microsystem level of the ecological model, OBS would appear to result from the effects of the worker’s interaction with his or her immediate environment, that is, with their workplace. Specifically, heavy workloads, lack of control, insufficient financial reward and conflicting values have been highlighted as some of the causes of burnout [31]. In relation to factors that can protect against OBS and promote health, research on the meaning of work [35] has indicated that skill variety and task significance make work more meaningful for the worker [38], as does congruency between an employee’s values and ideologies and the mission of the organisation [39]. Although there are multiple perspectives and theories on the meaning of work [35], many describe it as an individual interpretation of the role of work in one’s life [40]. For this reason, in this article, we analyse the meaning of work in relation to OBS among MT workers at the microsystem level, in order to explore the possibility of counteracting the effects of burnout. On the other hand, in addition to workplace conditions, it is also important to analyze the social relationships that each worker establishes with the various people with whom they interact in each of the micro-systems in which they participate. These include their own families and their co-workers, but MT professionals also frequently interact with other professionals, such as fire-fighters, police and doctors, as well as the users of the MT services. These relationships may cause stress or, on the contrary, be a source of satisfaction and well-being.
At the level of the mesosystem, explaining burnout requires an analysis of the interactions between the various microsystems in which the individual participates, especially –although not exclusively –the relationships between the family and work microsystems. MT professionals interact, for example, with the hospital system. This means that the structures, cultures and work practices in health facilities can influence MT working conditions or the relationships established between the workers. In some cases, this may be a source of conflict and stress while, in other cases, it may facilitate work or provide opportunities for exchange and for creating good relations. In this sense, several investigations have pointed out on the importance of analyzing the compensatory interactions between microsystems (or cross-domain compensation), as a protective factor against OBS [41]. It is, therefore, necessary to analyze how MT professionals perceive the interactions between the different microsystems in which they participate.
At the exosystem level, we need to consider the interaction between the workers and the regulations laid down by institutions and local government, as well as other environments which affect their work despite their not being present or directly participating in them. The institutional theory proposed by Dimaggio and Powell [36] offers a theoretical framework to explain the causal factors of burnout at this level of analysis. Their theory is centres on an understanding of organizations, at both the structural and the behavioural level. Specifically, they defend the idea that, although each institution has its own organizational model, these institutions are constituted by a particular set of rules, frameworks and laws that mean changes tend towards homogeneity They refer to this as isomorphism of which there are three types affecting institutions: (i) coercive isomorphism, resulting from pressures exerted on them by other organizations; (ii) mimetic isomorphism, from imitating more successful organizations; and (iii) normative isomorphism, arising from the norms or regulations that all institutions must comply with. In the case of Medical Transport, institutional and/or local government regulations are of great importance, since most of the organizational models worldwide are directly related to public institutions, either because the MT companies are run by government bodies, or because they are managed by private companies that must win a government contract via public tender. In either case, compliance with the regulations (normative isomorphism), the relationship with local/state government (coercive isomorphism) and, in the case of private companies, competition (mimetic isomorphism), there is either a positive or negative influence in the workplace.
Finally, burnout is analyzed at the macrosystem level of Bronfenbrenner’s ecological model. At this level, we can analyse workers’ perceptions regarding the influence of the current socioeconomic situation, the changes in labour patterns and the organization of work that have caused a culture change in business and global production models, cutbacks in companies and greater insecurity in terms of employment and working conditions. On the other hand, at this macrosystem level, we must also take into account the profession’s social image and public recognition as possible risk/protective factors [31], to the extent that, when these are negative, they can lead to loss of self-confidence among the workers. Social recognition theory [37] offers a good framework for analyzing how MT workers perceive the social image of their profession and would help to explain the low levels of personal fulfilment which, according to Maslach and Leiter [31], gives MT professionals the feeling that society conspires against any success they may achieve and exaggerates their failures, with the consequent loss of self-confidence. According to Honneth [37], little or no recognition causes the greatest damage to a person’s self-esteem. Individuals construct their own identity from the various ways they are recognised by society. Following Hegel, Honneth defines three forms of recognition: (a) relationships of love and friendship that take place in the private or family sphere; (b) legal recognition, in the public sphere; and, (c) solidarity, at the community level. In this last area, recognition of professional groups is formed as a result of the ideals and aims of the group as a whole. Individuals feel proud to belong to these groups, to be a useful part of the set of values that their collective represents. Conversely, when there is no recognition, or else disdain, then in addition to being an injustice, it can cause people harm. At the community level, such disdain affects the person’s dignity, their honour or status, leading to devaluation and a loss of self-esteem [37], concepts that are comparable to feelings of incompetence, a lack of motivation, reduced self-esteem and failure that are characteristic among OBS sufferers in the dimension of personal fulfilment. The work of paramedics or EMT technicians, depending on the pre-hospital model, has evolved considerably in the last two decades, with changes in both training and professional areas approaching that of other health professions [42]. Despite these advances, the literature on the subject points to lack of recognition as one of the causes of professional burnout in the MT sector [25, 43]. On occasion, this lack of recognition is linked to the history of the profession; it must be remembered that, in the early days, those who worked in ambulances –with little training or professional practice –merely carried out their job of transporting the sick and injured to a medical centre as quickly as possible so that expert medical personnel could attend to them [43].
The various interactions outlined above (the wor-ker with the workplace, with their co-workers, with the institution and with society –as well as the interactions among all of these) produce implicit situations that may be perceived positively or negatively by workers and that may constitute potential factors of risk and/or protection against OBS among these professionals. In this study, we consider it important to perform an analysis that includes these factors from the point of view of the professionals themselves, with the aim of finding out more about their own reality, since although there are a number studies that have investigated the possible causes of burnout, little is known about the resources to prevent it. Likewise, we considered it important to carry out a differential analysis between the professionals working in the two main pre-hospital models.
To this end, the following objectives are defined: To identify the possible risk/protective factors involved in occupational burnout syndrome (OBS) from the perspective of medical transport professionals working within either one of the two main pre-hospital models, the Anglo-American (AA) and the Franco-German (FG), differentiating between emergency MT and non-Emergency MT in the latter case. To gather contributions from the professionals on possible ways to promote the protective factors involved in OBS identified in MT services, with the aim of preventing OBS in both types of pre-hospital model –the FG model (which divides the service into EMT and non-EMT) and the AA model (which does not).
The FG model we chose is the MT system of Catalonia in Spain (divided into EMT and non-EMT divisions and emergency health technicians) [44] while the AA model analyzed is the management system used in the Quebec area of Canada (MT & techniciens ambulanciers paramedic) [45], the aim was to detect any possible differences or similarities between the two systems, that may, in the future, help to define working practices that are positive for health.
Method
Design and data collection
In the present work, qualitative methodology is used to analyze MT workers’ perceptions of risk/protective factors involved in occupational burnout syndrome, as well as their suggestions for preventive action.
Semi-structured, in-depth interviews were used to gather information, providing access to each person’s point of view, bringing us closer to the reality of their working environment and their interaction with their context [46]. Face-to-face meetings were scheduled between the interviewer and the participants with the aim of getting to know the focus of the interviewee in terms of their experience or practice, in this case in relation to their work environment and to OBS. Twelve interviews were carried out, having first obtained in most cases authorization from the entity –company or union –to which the participants belong, until the theoretical saturation that is required in qualitative research was reached. The interviews were carried out in two different stages. In the first phase, the interviews in the FG model were carried out and analyzed, followed later by those of the AA model. It was felt that it would be difficult to explain the role of the sociocultural context and the working conditions of MT professionals if we only analysed a single work environment (the FG model), which was why a different sociocultural and social/labour environment (the AA model) was selected. This procedure allowed us to compare the two models in more detail during the second phase of the research and, especially, by comparing the two environments, to clarify the role of working conditions and other contextual factors in professional burnout.
In the case of the Franco-German model, 6 infor-mants from Catalonia were selected. Purposive sampling of the participants was carried out according to heterogeneity criteria regarding job position (EMT versus non-EMT) and gender. In the Anglo-American model, 6 informants were chosen, in this case from Quebec. The selection was made by snowball sampling, since purposive sampling was difficult. Despite this, participants were asked to take into account the gender criterion when seeking out new volunteers, but since the AA model is not divided into EMT and non-EMT, this second criterion was not taken into account. Table 1 provides the relevant information on the participants in this research.
Participant details
Participant details
(*) CAT (Catalonia); QC (Quebec).
The semi-structured interviews were designed in accordance with the objectives of the study itself and the theoretical review carried out [24, 47]. The script was then read and approved by three experts with knowledge of the methodology involved, the MT sector and any local peculiarities, thus ensuring the internal and external validity of the technique used. Although the interview script was similar for the two MT models, some questions were adapted to each context depending on the particular characteristics in each case. The questions were grouped into six blocks: job characteristics, working conditions, professional burnout, protective factors against OBS, training, and (only in the FG model, where the EMT and the non-EMT are divided) the work schedules. The interview procedure was as follows: at the beginning of each meeting the participants were informed of the intentions and aims of the research, as well as of the confidential nature of any data that connected the person with the information provided. We requested permission to record the session to avoid loss of information, inviting the participant to continue with the process or freely decline to do so if they had any objections. The anonymous treatment of all information obtained in the interviews was also guaranteed.
In the case of the FG model, the person who conducted the interviews had previously maintained a working relationship with the participants, which had ended one year before the investigation, and had extensive knowledge of the company involved and access to documentation. In order to question the implicit assumptions and reduce any possible bias arising from emotional involvement and knowledge of the company and the informants that this ‘insider’ may have had [48], we tried to follow a process of reflection and constant discussion within the research team. In the second phase, the interviews were conducted jointly by two people who had no prior relationship with the participants. The interviews lasted between 50 and 110 minutes and all of them were recorded and transcribed verbatim.
Thematic analysis was used to analyse the information. As indicated by Nowell, Norris, White and Moules [49], the thematic analysis method is useful in performing comparative analyses among the experiences of research participants, in identifying emerging issues not anticipated by the researcher and in synthesizing large volumes of research information in a structured way. The interviews were analyzed with the help of NVIVO 11 computer software, following an initial a priori thematic coding based on the Bronfenbrenner’s ecological model [32] and an open coding for each of the levels of analysis of the model, with the aim of identifying codes and categories related to the various factors of risk and protection regarding health at each level.
Results
Factors of risk/protection involved in occupational burnout syndrome
In relation to the first objective, which was to identify the possible risk/protective factors involved in OBS from the perspective of the professionals involved, the results of the interviews are structured within the four levels of Bronfenbrenner’s model [32]: the micro-, meso-, exo- and macrosystems.
Analysis of the microsystem
With regard to the first level, the microsystem, the interviews with professionals allowed us to identify three major groups of risk/protective factors concerned with health: (I) the nature of the medical transport service itself, (II) working conditions and (III) interpersonal relationships at work.
(I) With respect to the nature of the service, it is necessary to differentiate between the EMT and non-EMT services. Eight participants, some from the AA model and some from the EMT of the FG model, indicated that the emergency service causes stress since it involves attending calls in which a human life is in danger, although they also indicate that this condition is an intrinsic part of the job and that it gives meaning to the profession, becoming a protective health factor. This, however, in some cases, involves feelings of guilt that generate stress as participants question whether they could have done anything else to save the lives of the people they are assisting. The vast majority of professionals explain that certain services are traumatizing and that many of them usually involve children. These services often lead to symptoms of post-traumatic stress.
“Me personally, ... the calls involving children; because our equipment is badly adapted, there is a kind of stress. Fortunately, it does not often happen that children are very sick but ... I do not know how to put it ... there are episodes of panic. The panic arrives in the end, even though the child is perhaps not so bad ... but when we get there, and the child is not well, there really is an extra stress, in relation to ... Possibly, because we do them less often ... with adults, we end up getting used to it .... These types of calls leave a mark.” (1QC)
On the other hand, workers in the AA model also point out that they perform fewer emergency services than is suggested by public imagination; this circumstance may imply that expectations generated during the initial training stage are frustrated and this can have negative consequences regarding the possibility of suffering OBS. In the experience of the interviewees in the AA model, only around 20% of services are real emergencies, whereas most of the initial training is focused on emergencies.
(II) Working conditions make up one of the main risk factors according to MT professionals in both models, mainly involving work overload, with the corresponding consequences of lack of time to rest, to eat and for other basic needs. Seven of the twelve participants (5 from AA and 2 from FG, in this case from the non-EMT group) consider that this variable is one of the main reasons for burnout in their work environment, to such a degree that, after a few years, work takes on a less positive meaning than it had at the beginning of their professional career, and there are even feelings of wanting to abandon the profession. The obligation to meet so many demands in a short time has a negative impact on the quality of the service and the treatment of the user. This is a complaint aired in both MT models and one which generates a strong degree of tension among the professionals.
“Er, yes, I would say, sometimes, it’s the services that follow one after the other. ... so, the number of calls has doubled. That’s for sure, but now, well, ... central calls you to tell you to hurry up, I have another call to give you straight away. People don’t have time to eat. Sometimes, you don’t even have time to go to the toilet, or anything, because you have one urgent call after another. ... Certainly that ... , that does not help with professional burnout.” (3QC)
“When I did non-EMT, sometimes we didn’t treat people the way they should be treated ... but that’s difficult to do when the service screen piles up and each service needs more time than the screen says, so you have to get to each address; each house and staircase have their peculiarities, they invite you, from the coordinating centre, to treat users like merchandise ... even if you don’t mean to ... if they give you 6 services and you have an hour to do them all ... ” (CAT1)
Certain business management methods are also a risk factor for professional burnout. For example, in the AA model, one participant provides information on the high rate of absenteeism, which he/she says is largely due to the management of holidays and rest periods that the workers want, but which sometimes cannot be satisfied due to lack of staff. This participant adds that, in one particular area, a high percentage of paramedics consume antidepressants, a fact he/she understands as a sign that there is a problem in relation to the psychosocial health of the workers. In the AA model, sometimes there is also a perception of excessive control and constant pressure on the part of the company towards workers. These professionals demand greater support, protection and trust when users make complaints –which are often unfounded –and greater recognition by the company (“... but we never get a pat on the back from our bosses; a slap in the face, maybe, but never a pat on the back.” 3QC).
“We are supervised ... very strictly. We can’t do anything without being blamed, and so on ... which makes it a source of stress. You ask yourself all the time, are you going to have to ... are you going to be checked out ... ” (3QC)
“... We are monitored by GPS ... what we’re doing, what our speed is, whether we use the flashing lights, the brakes, what our acceleration is, etc. If we end up in big shit, they’ll pull it all out ... All day long, they know where we are, what we’re doing ... that is what gets turned into stress, cynicism ... ” (5QC)
Despite this, however, the workers are also aware of the pressure that companies are under from public administration.
Another factor that worries the participants of the FG model, specifically in the non-EMT services, is the coordinating centre for non-emergency services, because of the way the services are programmed and managed, in addition to how they themselves are treated by the coordinating centre and the consequences this has on the service.
“In the non-EMT, they want you to treat the users like merchandise, the ones who do the scheduling, and maybe it’s not their fault either, because they’ve got limited resources and they have to fit 800 services into 50 ambulances.” (CAT1)
The work schedules are worrying to the professionals in both models, due to limited choice of vacations or the accumulation of hours worked, or other variables that affect work-family or work-life balance. For example, the on-call 7/14 shift* in the AA model, agreed through collective bargaining, is also an adverse factor according to the professionals, both in terms of work-life balance issues and of the quality of the service provided. Other factors are considered by workers from both models to cause burnout, although to a lesser extent. These include weather conditions, exposure to muscle injuries, waiting time during the triage of patients during emergency services, the lack of, or the poor state of, resources (especially the vehicles), and incoherence between different regulations regarding speed limits. More particularly in the AA model, the risk factors include the need to care for people with psychiatric disorders (involving substance abuse, mental problems, suicides, etc.), because such services are of greater complexity, there are risks to one’s own safety and they feel they do not have enough training on managing these types of users.
(*) In this shift, the workers may stay at home rather than in the workplace, but must remain locatable and on call for seven 24-hour periods during 14 days.
On the positive side, the factors promoting health protection at the microsystem level that stand out include improvements in working conditions related to the resources and technology available compared to previous eras, as well as the change in mentality:
“From a medical point of view, the mentality has changed a lot in the last 4 to 5 years, before it was all about sanctions; they sent you letters for minor or major cases, for everything! Now this has changed a lot! It has changed thanks to quality management in medicine; now it’s the paramedics who are there, who understand the situations ... ” (1QC)
(III) We analysed four different groups of professional relationships: those with colleagues who were usually in the same ambulance crew as the participants, those with other professionals, with company managers and with the users or their relatives.
All the participants from the AA model and from the EMT of the FG model declare that their companion is like their partner or spouse in the work environment and, therefore, that a good relationship is needed to carry out their work; they speak of trust and teamwork. They also point out that, when the relationship is positive, their partner becomes their confidant, their psychologist or their psychological support, including for personal issues, and that this is a protective factor for their health. (On the other hand, a bad relationship can change the day-to-day so completely, they can end up not wanting to start the working day).
“I have seen some, ... I know of colleagues who were depressed and suicidal who continued to work and it’s their partner who gets them back on track, socially speaking. Like, there are so many years of camaraderie ... that’s why they come back to work and feel supported ... it’s the partner who’s said ‘You’ve got no choice, so stop, let’s get you some help because I know you and it’s not okay’. There are some who create great bonds, a great circle; what you get from your work partner is huge support, especially if you’ve been working together for several years, no matter how close you are.” (2QC)
Professionals in the AA model indicated on several occasions that they prefer to talk about their worries to their colleagues rather than using the Employee Assistance Program (EAP) set up to provide psychological help for employees in Canada, because they consider that psychologists are unacquainted with their sector, a fact that distances them from the reality of their work. Only one interviewee mentioned the existence of La Vigile, a therapy centre with accommodation for emergency service workers. Also in the AA model, participants complained that it was only possible to request a change of partner once a year, when the work schedules were handed out, and this was adjudged to be negative given that, if a problem arose with a partner, the year’s programme still had to be completed. Similarly, having to change partners during vacation periods was also considered negative. In contrast, the possibility of choosing one’s partners was considered a positive factor. It should be said, however that in general, most of the interviewees perceive their relationships with their companions in a positive way.
As for the non-EMT section in the FG model, the participants make it clear that they work without a partner most days, so relationships are not as close.
With regard to the relationships with other professionals, again in both models, the respondents differentiate between three groups: health professionals (medical and nursing staff), fire-fighters and police (or security) forces. Participants in both models consider that they have better relations with nursing staff, due to close proximity at work, with a good degree of collaboration. Some resentment is perceived toward the medical staff, stemming from the position of superiority attributed to doctors:
“In the health system, doctors ... He’s God, the one who decides; he’s the one who gives the prescriptions; he’s the one who decides. So in the hierarchy of the hospital, it’s always the doctor who is higher than everyone else” (2QC).
The relationship with fire-fighters is not mentioned as much in the AA interviews as it is by FG participants, who believe that fire-fighters sometimes believe that they can carry out the work of the emergency health technicians and, in some cases, a relationship of superiority is perceived that generates a certain degree of tension and competition.
“For example, with the fire-fighters ... it’s about showing who is the Man ... the fire-fighters have to make the area safe, but they go beyond their tasks and play paramedics, policemen ... real heroes! Real heroes they are ... [in ironic tones]” (CAT2)
Relationships with company managers in both models are considered, for the most part, as negative. They feel a lack of company support in the face of complaints from users or their families. Participants from the AA model highlight the excessive supervision or control of their work and a lack of understanding, humanity or closeness, as well as inequality in the treatment of workers by their managers. Workers from the FG model indicate that managers do not know how to listen, to communicate and to inform; they find them lacking in resolution, and complain about their indifference and the inequality in their treatment of workers.
“Yes ... the different ways they treat people ... you get cases where someone isn’t due personal days and yet they get them: in other cases, someone is due personal days and they don’t get them ... It all depends on who you are ... That wears you down” (CAT6)
Especially among the workers in the AA model, there are complaints of excessively bureaucratic and distant management. In this regard, they comment that the company might send out notes thanking the group as a whole after a particularly extraordinary intervention (for example, during floods, snowstorms, etc.), but they do not receive recognition on a day-to-day basis.
Finally, with regard to the relationships with users or their families, they are generally valued as positive in the AA model, since the service is generally brief. In the FG model, however, participants indicate that the relationship with the user may in some cases become negative in the long term, that is, in non-EMT services where the relationship with the users may go on for days or months, and where adequate care may need to be provided for chronic patients or those with terminal illnesses, which means such demands can become emotionally exhausting.
Analysis of the mesosystem
Analysing the mesosystem means identifying those factors of risk/protection in psychosocial health related to the interactions between the various microsystems in which MT workers are involved. From the interviews we conducted, it appears that interactions arise between four microsystems: (I) family-work; (II) MT-hospitals; (III) MT-geriatric centres; and, (IV) MT-fire departments.
(I) Interactions between the family system and work, in both directions, appear often in the respondents’ narratives. On the one hand, work affects family life negatively in several ways: a) the difficulty in balancing work schedules on 12-hour shifts that prevent them taking their children to school or finding nurseries when working such long hours; b) working schedules that leave insufficient time for rest and respite, causing bad feelings that have negative impacts on family relationships; and, c) the emotionally demanding nature of the service, which sometimes causes stress and suffering that ends up affecting the family.
In the opposite direction, the family microsystem also affects work. One of the protective factors highlighted is the possibility of sharing emotions and worries with one’s partner/spouse. On the negative side, the fact of having children makes emergency call-outs involving children highly traumatizing; in such cases, the images and thoughts about their own children are very present during and, above all, after the service: “things that didn’t use to affect me, do affect me now ... ; time passes, I have a daughter now.” (CAT3):
“A former colleague of mine went out on a call; a boy had drowned in a swimming pool ... he told me all about it, ... it’s like a flashback, it’s ... because it’s so easy to project it, like, if it was our own son ... (...) so because of our attachment, we don’t want it to happen to us ... it affects us, emotionally [She explains that the event where the child drowned was a barbecue and that her former partner could not bring himself to go to a barbecue for a whole year]. Everything associated with the event is traumatic for him (2QC).”
Also, when the service involves workers risking their lives, thoughts of family and the possibility of not being able to see them again is ever-present during the intervention: “They are there, too; my children, my partner, my friends, my mother ... ” (CAT2). Attending a call-out involving members of their own family is considered equally traumatizing. Furthermore, the fact of having a family is considered a risk factor due to job insecurity in the workplace or the fear of changes in working conditions, which can threaten the security and well-being of the family. Finally, participants mentioned that difficult family situations, such as separations, illnesses, etc., can negatively affect their work or the way they treat users (less patience, greater irritability) if such emotions are not managed properly.
The problem of gender and the double burden appear in one of the interviews in relation to the feminization of the role and the problems of work-life balance; in the first case, the interviewee points out that becoming a mother has positively influenced her professional role, bringing a change of perspective in the way she deals with her work and incorporating an ethic of care in dealing with clients:
“I’ve become more feminine in my work; when I started out as paramedic, I was very masculine. When I got in, in 2001, there weren’t many women ... I was always hearing that the girls needed technical support ... blah blah blah ... and I just tried to get on with it. But since I’ve had the children, I’ve become a lot milder; I’ve become more feminine, and so big biceps don’t interest me anymore; I don’t train any more for heavy loads .... But in terms of patient contact, the actual medical intervention ... I feel very competent in that ... ” (5QC)
Regarding the difficulties of work-life balance, this person made the decision to prioritize family life over work, which involves a certain sacrifice. This view was accompanied by a criticism of people who make their working lives their only priority:
“I think the mistake made by these paramedics who are exhausted, who’ve become cynical, is that their life is the company ... they’ve got no love life, no friendships ... they’ve got no ..., well, they’re empty ... I think that’s the worst mistake” (5QC)
(II) Interaction between the MT microsystem and that of the hospital is mentioned only once during the interviews in a reference to the fact that there are some days when the hospitals are over-burdened and the staff are agitated, and this is passed on to the MT workers, thus affecting their own work.
(III) With regard to geriatric centres, problems arise when non-EMT workers have to collect patients who have problems with personal hygiene, bad odour, etc., which they attribute to the fact that the centre only bathes these patients once a week.
(IV) Finally, in both the FG and AA models, participants refer to a certain tension and competitivity between MT professionals and the fire departments that seem to go further than mere interprofessional relationships. Whether true or perceived, there is a belief that fire-fighters think of themselves as higher up in the hierarchy and that they act superior towards MT staff; they also appear to enjoy greater social recognition and this affects relations between the two groups and how day-to-day services are carried out. This does not, however, prevent good professional relationships from being established on a personal level, or social activities outside work being organised jointly.
Analysis of the exosystem
With regard to the exosystem, five of the six professionals from the AA model believe that the current model being implemented by institutions for medical transport generates work overload in their day-to-day tasks for several reasons. In the first place, while they confirm there is an increasing demand for ambulances by society, manpower has remained practically the same:
“The government. They’re the ones who set the rules of the game. They’re the ones who issue ... who issue work licences to employers, who say you are entitled to this many vehicles, this many people. Uh, and the ... the training ... comes from the Ministry. Uh, and the ambulance station ... if an employer puts a station in such a place, well, they have to check it out with the Ministry to see whether it’s okay, or not. It’s ..., it’s when there are peaks of calls –that’s when most of the calls are made trying to get more vehicles, as many as possible. But, it’s down to the Ministry really.” (6QC)
The participants point out that the law governing “services préhospitaliers d’urgence” [45] offers EMT service to all citizens, thus generating the need to cover services which, on occasion, sometimes would not require this pre-hospital emergency transfer. On the other hand, they mention that the system of triage in healthcare facilities sometimes leads to ambulance resources being retained. The ambulance system –or rather the health system –is not seen as very functional, with a certain distance existing between the MT staff and the managers in their offices (for example, unrealistic speed limits are set):
“The worst thing is working in a system –and it’s not only the ambulances, it’s the whole health system in Quebec –which is totally archaic and not very functional. There is a kind of disconnection between the base and the leaders up in the office. Often, the decisions made in committees, in terms of how applicable they are in the field, well, we end up saying it won’t work ... but on they go ... when the theories that are beautiful on paper arrive on the ground, they don’t work ... ” (1QC)
Among the participants from the FG model, both EMT and non-EMT, factors of risk for occupational burnout also appear in reference to the institutional system. Specifically, the fact that they work for private companies, rather than being part of the public administration, is viewed negatively because, among other reasons, there is concern and uncertainty generated by knowing that, from time to time, the company employing them can be replaced along with their management model, each time the public tender is renewed. Comparisons are made once again with the fire and police departments:
“The health care world can’t be private ... Companies are there to make a profit, the health care world shouldn’t be private, health focuses on the user, not on the economy.” (CAT4)
“The police and the fire-fighters don’t have this problem ... why is it that in the medical transport services, we have to privatize the workers? Privatize the companies, not the workers! ... That is, a new company can come in and take on the workers (as they’ve done up to now) but also [maintain] the conditions ... And if you need to pass 5-year tests to keep your job and not get too comfortable ... then, so be it ... Nobody’s ever thought about saying ‘let’s reduce the police force because now there are fewer crimes’ ... ” (CAT2)
They also point to the cuts that have been applied to companies by the Administration as a result of the economic crisis, resulting in job insecurity and changes in working conditions: “the public tender process brings changes ... everyone talks ... everyone says what they think and it gets passed around; the uncertainty this provokes generates discomfort, stress ... ” (CAT5). On the other hand, they complain that all calls are handled as if they require the ambulance service rather than using certain filters; and that the companies managing the MT service can get around government rules on public tender, as well as sectoral agreements governing labour conditions, without checks of any kind.
Also at the institutional level, a number of workers from both models say that their work lacks legal recognition; in the case of the AA model, in Quebec, they believe they should be members of a professional body while those in the FG model insist that they should be considered as health care professionals, as stipulated by the law [50].
Training appears in the interviews as a factor of risk as well as protection. In both models, a noticeable improvement has been seen in the initial training provided to professionals compared with previous periods. Training is considered to be much more thorough, and this is felt to provide greater security and gives greater prestige to the profession by equating it with other professional groups. However, a certain resentment is apparent towards other health professionals who do not always recognize their professional status on equal terms or when, attending a scene, they are prevented from dispensing certain medications, especially in the AA model. Despite the improvement experienced in the initial training period, they still see certain gaps in their training, including lifelong learning, in comparison with other specialist groups in the emergency services who receive ongoing training for high-risk interventions. Participants from both models feel there is also a need for more training in terms of their own personal health care, especially regarding psychosocial risks.
Analysis of the macrosystem
Finally, at the macrosystem level, four major risk factors for the health of MT workers were identified: (I) the global economic crisis, (II) changes in business management models, (III) professional recognition and, (IV) individualism.
(I) The economic crisis has had a generalized effect across all types of work in the western world. In the case of MT, it has resulted in work overload and significant cuts in resources, both of which are perceived by the workforce as sources of stress:
“Good things you used to have can also get worn out ... for example ... you have heating and air conditioning and it’s taken away, you have beds and they replace them with armchairs ...; when you cut your quality of life, you notice it ... ” (CAT2)
“You see the cutbacks all around you; your friends are becoming unemployed, jobs are lost, members of your family need your help and your company might be losing the contract ... and new ‘bosses’ will come ... these are huge changes ... ” (CAT2)
(II) One of the complaints often heard from the participants is related to an increasing bureaucratization of business management and changes in work systems and procedures, which results in greater pressure and control over employees, and a colder and more distant labour relations model, which ends up affecting their quality of life and the service they provide to users. Although the participants blame their company’s management team for these changes, it should be considered as a global trend within the framework of the macrosystem level and one that affects all the other levels below it –the microsystems, mesosystems and exosystems.
(III) With regard to recognition, four of the six respondents from the AA model do feel that their work is recognized by society and that this has a positive effect on their work. A simple smile or words of gratitude from the users is part of this recognition and gives meaning to the work they do.
“In fact, on the contrary, it’s our lifeline, it’s everywhere: ‘You do incredible work’; ‘Thank you for the ... ’ Me, what I like is when you stop the vehicle and there are people who come over and talk to us, who come and tell us things ... ” (1QC)
“In Quebec, it’s the most highly-recognised profession ... we went ahead of the fire-fighters three years ago ... ” (4QC)
One of the two other respondents from the AA model felt their profession was not recognized and the other said that recognition depended on the circumstances, since he also believed that, in general, society were ignorant of their work. In half of the cases, the subject of recognition inevitably brought up a comparison with fire-fighters, For example, while one respondent considers that their work is better recognized than that of fire-fighters, two others consider that, while their work in MT does get some recognition, it is far below the level of recognition extended to fire-fighters or paramedics in other provinces of Canada, such as Ontario or in United States. Similarly, among respondents from the FG model, two of them consider that their work is recognized by society while three feel that they are not and the other believes that it depends on the circumstances, because the public lacks information about their functions. Although among the EMT staff there are both positive and negative perceptions regarding social recognition, none of the non-EMT staff, think that their work is recognized as it should be.
“What happens is that, at the user level, there is some misinformation about what our work entails. Talk to a user or their family and they think you’re the driver of the ambulance, nothing more ... they think a medical technician is a nurse, they don’t think about ambulance technicians. I think there is a bit of misinformation about our work.” (CAT1)
(IV) Under the heading of individualism, we have put together a group of narratives that mention individual ways of dealing with job stress in the MT sector, but which reflect a general feature of present-day Western societies. In the narratives of the participants, certain recurring metaphors appear, such as a protective shield, a wall, a veil, or shell:
“when you show your more human side, your shield is down, that’s when it affects you most ... ” (CAT2); “I drop my wall so I can attend to the task and, afterwards, well I raise my wall when I’m finished.” (6QC); “ ... a veil to say: ‘I’m here to do a job’ [ ... ] when I lift my veil, it’s to be there when we begin to come down [decompress], and then that’s where we say, ah ... so I managed it. They’re little tricks I use.” (6QC); “we make an impenetrable shell for ourselves” (2QC).
With metaphors such as these, the respondents attempt to explain how they protect themselves from the emotional demands of their work. They have learned to deploy such strategies by themselves, from their own experience, to prevent themselves being overwhelmed by emotions and from feeling excessively responsible. They are a reflection, however, of how the whole sector, and society in general, understands coping with stress as an individual question. In the same sense, they recognize that the subject is only to be discussed, if at all, with a co-worker. The shame and stigma attached to mental illness makes it difficult to seek professional psychological help; mental health problems and emotional outpourings are a professional taboo, as is the case in among security forces and fire-fighters:
“People are afraid to say ‘I have a problem’ ... There is the shame of mental illness ... ” (1QC); “In general, no paramedic wants to acknowledge that they may be depressive or bipolar, because that is initially associated with the end of the end; that they’re always negative, that there are no happy stories.” (2QC)
In the same vein, among the more experienced workers there is a kind of ‘survival-of-the-fittest culture’ that equates a long career in the sector to individual psychological strength –which they confer on themselves with a certain pride: “I still keep going on. No need for a psychologist yet” (6QC). Individual differences are repeatedly mentioned as a way to explain how some people cope with emotionally complicated situations:
“I think there are people who are built for it and others who aren’t ... I don’t know if it’s possible to train for it ...; it’s important that people who aren’t built for it know it.” (5QC); “You’re either built for it or you aren’t ... If you are not built for it, don’t go there.” (6QC)
It is surprising that, throughout all the interviews, there was only one mention in the AA model of the collective as a way of coping with stress:
“Well, we have ... we have psychologists, but we often talk colleague to colleague. When we’re on a job, when we arrive at base and, all of us colleagues together, we’ll talk about our cases, without naming names. But we’ll say, like, I’ve done this ... I’ve just come back from such and such ... I should have done this or that ... and that’s where, we ..., we communicate together. It’s how we manage to get through it all. We’re like a family, basically.” (6QC)
To cope with this situation, various solutions are proposed, depending on the management model. In the case of the FG model, several participants propose more psychological training during their studies, and the incorporation of psychology professionals in the company so that they can talk about the complicated services or the emotional demands that come from work. In the AA model, which already includes psychological services for employees, this figure of the psychologist is distrusted because they do not know the specific problems of the sector well “The psychologists aren’t adapted to our job yet” (6QC). In any case, using psychological services does not stop it being an individual coping solution. Some participants in the AA model with longer careers in the profession propose collective solutions: changing the culture of the sector and talking with colleagues:
“Change the mentality of the bosses completely so that it is no longer taboo ... Make it natural to share our experiences, so that it becomes almost commonplace to talk about it, and change this attitude properly.” ( ...) “Have a system where we can talk with someone who has gone through similar situations; establish a crisis management team, or team on call you can count on, who know the reality of paramedics, who can ask us ‘tell me about yourself, tell me about your feelings ... ’; talking about it is what gets most it out of the way ... speaking with someone who understands our reality ... ” (1QC)
Finally, although to a lesser extent, it is also worth mentioning how society’s view of childhood as a stage to be protected and in which suffering should be avoided ends up disturbing MT professionals when they face situations in which the life of a child is in danger.
“Well, the hardest thing for me, through all the years I’ve been working, is ... is that ... there’s so many children. I have a lot of difficulty with that. Because children, we say it all the time, the children shouldn’t be suffering” (6QC).
Actions suggested by MT professionals to promote protective factors against OBS
Our second objective was to gather ideas from MT professionals to promote protective factors against OBS, and in this regard, some of them say that a number of what they have previously described as risk factors for OBS could be turned into protective factors (for example, relationships with colleagues, the design of work and vacation schedules, and longer rest periods after situations that may generate trauma, etc.); making it possible to find solutions through policies of participation or cooperation among all those involved.
On the other hand, they suggest that a psychological support team be on hand, all day and all year, who can be called in crisis situations, in case of need. Although respondents from both models share this view, those from the AA system –given their experience so far of psychologists unfamiliar with the sector –insist that this support team be made up of people who are aware of the everyday reality of paramedics. Participants from both models also very frequently point out the need for ongoing training sessions or workshops that simulate ambulance operations on the road, in order to learn about, understand or train for unpredictable situations; in other words, training to improve the skills needed to improvise and find solutions in such situations, which is lacking during initial training.
Occasionally, the possibility of sharing spaces with other professionals is mentioned, with the aim of improving cross-team collaboration and, consequently, the relationships between the various teams of first responders. In addition, they mention the importance of creating working groups where they can share experiences and/or situations, in order to discuss, learn, understand, and get to know –among other things –the day-to-day reality of the paramedical technician in the light of their experiences. Finally, on the subject of training, participants from both systems share the view that training in social skills is needed, both to help others as well as themselves.
Respondents from both models refer to another area ripe for improvement, and which might help prevent OBS, and that is the possibility of creating a climate of trust with management teams, as well as improving communication and information with regard to their working environment. When it comes to resource management, they propose incorporating their own knowledge, experience and day-to-day needs in decisions affecting the purchase or design of vehicles. Similarly, they would like to participate, or have their concerns taken into account, when work schedules are drawn up or unpopular schedules are modified, in order to improve their work-life balance. Finally, in relation to this objective, there was the suggestion from some in the AA model of the possibility of implementing a cross-team working group bringing together various professions (paramedics, nurses, doctors, social workers, physiotherapists, social workers, etc.) to reduce work overload. Furthermore, depending on the triage of calls in the coordinating centre, appropriate resources should be allocated where needed most, thus avoiding the displacement of paramedics to situations in which a different type of service is required.
Finally, participants from the FG model, with regard to the concerns that arise when public contracts are up for renewal, suggest that they become government employees, rather than being employees of a private company. Furthermore, they believe they should be tested, on a regular basis, on their job competence and their physical fitness.
Discussion and conclusion
To the best of our knowledge, this study is the first that compares how MT professionals from two different models, (i.e. Anglo-American and Franco-German) perceive the risk/protective factors involved in OBS, while differentiating, at the same time, between EMT and non-EMT staff in the Franco-German model. The data obtained provides a des-cription of the risk/protective factors involved in OBS among MT professionals, which could be highly useful to decision-makers in management roles in the sector, whether public or private. The information obtained may contribute to improving psychosocial health in the sector, in addition to avoiding negative consequences for users or the organizations themselves [29], as well as transferring good practices among the different MT models.
The results of the study show the multi-causal nature of OBS, with risk/protective factors interacting throughout the different levels of Bronenbrenner’s ecological model [32]. In general terms, we would conclude that there are more similarities than differences in the way professionals from the two models (AA and FG) perceive the risk/protective factors, while some differences appear between EMT and non-EMT professionals within the FG model. Among the three main groups of risk/protective factors found at the microsystem level, one of the most often mentioned among professionals is the stress generated by the very nature of the emergency service, except, in this case, among those performing non-EMT tasks. However, we can see that that the stress of emergency situations is actually understood by these professionals as a positive concept, in line with the theory on the meaning of work [35], in the sense of using diverse skills [38], or by the increased adrenaline generated [51], or by the fact they are providing help to citizens in a situation of need. The professionals also highlight the relationship with colleagues as a positive factor; a result which is also found in another study in the same FG model [52]. With regard to working conditions, another of the three main groups of risk/protective factors found in this study, Maslach & Leiter [31] indicate that work overload is one of the causes of burnout, in line with other studies of the sector [53]. In our study, there is a consensus among professionals from the AA model, and from those in the non-EMT division of the FG model, that overwork is one of the main factors of occupational burnout. Furthermore, still on the subject of working conditions, Sacks [54] states that when an organization does not provide the economic or emotional resources seen as necessary, workers are more likely to dissociate themselves from their role. Some of the participants in this study are unhappy with certain aspects, such as how work schedules are determined, or the relationship with management, among others, to the point that these factors become risk factors that cause lack of involvement and motivation, and may negatively affect the results of the organization and its productivity. Another study conducted with emergency medical technicians and paramedics also points to similar results, including the lack of trust between supervisors and workers as one of the recurring concerns among these professionals [55].
In relation to the mesosystem, the results of the study illustrate multiple interactions, especially between work and family. In line with previous studies, there are factors that compensate for each other for example when the family absorbs some of the stress generated at work, or when co-workers become a source of social support in the face of family problems [41].
At the level of the exosystem, the work of Dimaggio and Powell [36] on institutional theory is partly reflected in the results of the study. Participants from the AA system consider that work overload is a consequence of the institutional design of the emergency services model and public sector management, with the need to invest yet more resources into the system, bearing in mind the continuous increase in demand for these services by their citizens. Workers in the AA model add that the law governing their sector (Loi sur services préhospitaliers d’urgence), is sometimes not in tune with demographic, social or other changes, and this can cause the service to become saturated and, consequently, the staff to be overloaded with work. In the FG model, with management contracts awarded via public tender, the staff have a negative perception of the heavy influence of economic factors on the current bidding system. That is, companies are required to present the best economic proposal to win the service contract or, periodically, to renew it. Subsequently, the proposals presented are often adjusted downwards, with a worsening of previously agreed labour conditions to the benefit of companies who win the contract. Such changes in working conditions spread to other organizations by mimetic force, as described in institutional theory [36], because of the economic advantage they can bring. Participants from the FG also say that certain regulations of the current emergency services system or of collective bargaining agreements for the sector are not adhered to or are not, in themselves, adapted to current needs, as other studies have indicated [47].
At the macrosystem level, the results reveal four groups of risk/protective factors: the global economic crisis, changes in business management models, professional recognition, and individualism. Regarding social recognition of the profession, Honneth [37] pointed out that the absence, or a low level of recognition can significantly damage a person’s self-esteem, and greater recognition could play a role as a protective factor among the MT professionals. In this study, more of the professionals from the AA model feel that society recognizes them fairly, than those in the FG model. The literature on the subject has already indicated that lack of recognition is one of the causes of occupational burnout in the medical transport sector [25, 43]. In spite of this, it must be noted that the evolution of the sector in recent years has also led to changes in the profession [43], in terms of both the profession itself and training. These changes in the sector may also contribute to the different perspectives on social recognition between both models. The sensation of more social recognition among the professionals in the AA system compared to those in the FG system may be due to the fact that they receive more training, and have more competences and functions in the working environment (e.g., they can supply certain medicines), and this could contribute to a greater recognition of their contribution to health care in society.
In light of the above, coupled with the results regarding our second objective, we have identified a number of factors that should be taken into consideration in order to improve the working environment of health professionals in order to reduce those factors that are a risk to their health and to promote protective ones. Doing so would make it possible to positively influence the interaction with users and the productivity of the company, regardless of whether it is managed publicly or privately. The areas for improvement suggested by the professionals relate to personal development, the business models and the institutional models. It was observed that several risk factors in these areas –at each level of the ecological model –could be turned into protective factors, and that this was true in at least one and sometimes both models of pre-hospital care, including both EMT and non-EMT divisions in the FG model.
There are certain limitations of this study worth mentioning. It would have been desirable, for example, to be able to contrast the results obtained with data from FG and AA models in other sociocultural environments, especially in countries outside the developed western world. On the other hand, it is important to bear in mind that all the participants in this study were exposed to additional stress factors during the research period. The public tender process for the company employing the participants from the FG model was underway and those from the AA model were on strike to demand the renewal of the collective bargaining agreement. Both situations could certainly have influenced the opinions expressed during the interviews, perhaps channelling some of the disquiet and job insecurity, or obscuring certain positive variables which, consequently, may not have been considered. It should also be mentioned that three of the participants from the AA model and two from the FG model were union representatives. For all of these reasons, we believe that it would be desirable to replicate this research in a period with less uncertainty or conflict in the workplace and, at the same time, to contrast the results with the views of other stakeholders, such as the MT companies, government representatives or the users of the system. Nevertheless, the situation of unrest among the workforce may have helped to bring to the surface their awareness of the risk/protective factors involved in health related to their working conditions. Therefore, despite these constraints, we believe that the results presented contribute an original approach to studying occupational burnout syndrome in the medical transport sector and provide numerous suggestions for improving the working conditions of the professionals involved.
Conflict of interest
None to report.