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IMPROVING PEOPLE MANAGEMENT IN EMERGENCY SERVICES

IMPROVING PEOPLE MANAGEMENT IN EMERGENCY SERVICES SUMMARYREPORT

APROJECTREPORTPREPAREDBYTHECENTREFORWORK,ORGANISATION&WELLBEING

A/ProfKeithTownsendA/ProfRebeccaLoudounProfAdrianWilkinson

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August2018PublishedbytheCentreforWork,OrganisationandWellbeingwww.griffith.edu.au/work-organisation-wellbeingStreetandPostalAddressBusiness3Building(N63),GriffithUniversity170KesselsRoad,Nathan,QLD4111InformationabouttheHealthoftheWorkplaceProjectcanbefoundat:www.griffith.edu.au/work-organisation-wellbeing/research/projects/improving-people-management-systems-in-the-emergency-servicesReportpreparedby:AssociateProfessorKeithTownsend,AssociateProfessorRebeccaLoudoun,ProfessorAdrianWilkinson,DrAshleaKellnerandDrTiet-HanhDao-Tran.Title:ImprovingPeopleManagementinEmergencyServices[SummaryReport]Citation:Townsend,K.,Loudoun,R.andWilkinson,A.(2018)ImprovingPeopleManagementinEmergencyServices,SummaryReport.CentreforWork,OrganisationandWellbeing,GriffithUniversity,Brisbane.

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Improving People Management in Emergency Services

A Summary Report prepared by Griffith University for United Voice Queensland, the Ambulance Employees’ Association of South Australia, and United Voice Northern Territory Written by Keith Townsend, Rebecca Loudoun & Adrian Wilkinson, Griffith University, Australia. The authors acknowledge the following financial support for the research: The Australian Research Council [LP160100004]. ForfurtherinformationcontactKeithTownsend:k.townsend@griffith.edu.au

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The Chief Investigators Keith Townsend is Associate Professor in the Department of Employment Relations and HumanResourceManagementatGriffithUniversity.

Rebecca Loudoun is Associate Professor in the Department of Employment Relations and HumanResourceManagementatGriffithUniversity.

AdrianWilkinson is Professor andDirector of theCentre forWork,Organisation andWellbeing atGriffithUniversity

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Acknowledgements This summary report is based on findings of the research project titled ‘ImprovingPeopleManagementSystemsinEmergencyServices’.Thisprojecthasbeenconductedwith the financial and in-kind support of our research partners United VoiceQueensland, theAmbulance Employees’ Association of SouthAustralia andUnitedVoiceNorthernTerritory.WealsoacknowledgethefundingprovidedbytheAustralianResearchCouncilLinkageGrantscheme[DP140100194].

Wewouldliketothankourcontactsateachoftheunionsforyoursupportoverthedurationoftheprojectandforprovidingusaccesstoparamedics,otheroperationalstaff,andcorporateemployeesacrossyourrespectivejurisdictions.Inparticular,wewouldliketothankGaryBullockforinitiatingthisprojectandDebbieGillott,FionaScalon(UVQld),PhilPalmer,RobLeaney,LeahDonaldson(AEASA),andErinaEarly(UVNT)fortheongoingcommitmentandsupportthroughoutthisproject.

The project research fellows – Tiet-Hanh Dao-Tran and Ashlea Kellner – have been valuablecontributorstothisprojectandwewishtothankyoubothforyourinputintothisprojectreportandprogressonassociatedacademicpublications.

TheviewsexpressedinthisreportarethoseoftheauthorsandnotnecessarilythoseoftheAustralianResearchCouncil.

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TABLE OF CONTENTS

SECTION1 TheHealthandWellbeingofParamedics...............................................................14

1.1. Post-traumaticstressdisorder............................................................................................15

1.2. Stress,anxiety,depressionandgeneralmentalhealth......................................................17

1.3. Physicalhealth....................................................................................................................19

1.4. Fatigue................................................................................................................................19

1.5. Workabilityandintentiontoquit.......................................................................................21

SECTION2 SystemsandSupportforParamedics......................................................................24

2.1 HumanResourceManagementSystemStrength...................................................................24

2.2 EmployeeSupport..................................................................................................................26

2.2.1 Formalsystemsofsupport..........................................................................................26

2.2.2 Peersupportprogram.................................................................................................29

2.2.3 Colleaguesandfamily..................................................................................................31

2.2.4 Frontlinemanagers......................................................................................................33

2.3 EmployeeVoice......................................................................................................................36

2.4 WorkPressures.......................................................................................................................37

SECTION3 AdditionalConsiderations......................................................................................39

3.1 Highreliabilitymanagement..................................................................................................39

3.2 Trainingforimprovedresilience............................................................................................41

3.3 Mealbreaksandreturntobaseprovisions............................................................................42

3.4 Changestoworkforceprofile.................................................................................................44

3.5 Futureavenuesofemploymentforparamedics....................................................................45

3.6 Paramedicsandthecommunicationscentre.........................................................................46

4 Appendices............................................................................................................47

4.1 AppendixA:ShiftfromDSM-IVtoDSM-5..............................................................................47

4.2 AppendixB:FullListofInterviewees......................................................................................49

5 References.............................................................................................................50

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Executive Summary revious research suggests that ambulance work is often characterised byemployeeburnout,highstress,workintensification,andexhaustion–physical,mentalandemotional.Amajorcontributingfactoristhatexposuretotrauma

isanunavoidablefeatureoftherole,andcanincreasetheprevalenceofanumberofmental health conditions such as depression, anxiety, and post-traumatic stressdisorder.

Thereisasignificantcost(financial,socialandemotional)ofmentalhealthconditionstoemergencyservicesproviders.Foremergencyservicesorganisations,mentalhealthproblemsareassociatedwithincreased sick leave (Brattberg,2006),deterioratedhealthandwell-being (Bergeretal., 2007)andincreasedemployeeturnover(Patterson,Jones,etal.,2010).Thisstudyhasaimedtobetterunderstandthe organisational factors that affect paramedic and support staff experiences of work andemployment,andtheimpactofthesefactorsonarangeofindividualoutcomes,particularlyassociatedwithpsychologicalhealthandwellbeing.

Toachievetheaimsof thisproject,weconducted1216surveysand72 interviewswithemergencyservicesemployeesacrossQueensland,SouthAustraliaandtheNorthernTerritory.Dataanalysishasdirected attention to some key findings, which are expanded upon in this Summary Report, andsupportedbydetailedstatisticalanalysisintheCompanionReport.Thekeyfindingsaresummarisedasfollows:

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§ A provisional PTSD diagnosis can be made for 10% of Queensland and 8.5% of SouthAustralian staff.Anadditional 6.6%and4%of respondents in each state respectivelywerefoundtobeclosetoaprovisionaldiagnosis.RecentchangesinthemeasurementinstrumentforPTSDhasmeantthatmanypeoplewhowouldpreviouslyhadaprovisionaldiagnosisarenowexcluded(seeAppendixAfordiscussion).

§ More symptoms of PTSD are reported by employeeswith longer tenure of employment.Thosewithmoresymptomshavehigherintentiontoquitandpoorerabilitytodotheirwork.

§ Socialsupportisakeyfactorinthesefindings,withthosereportinggreatersupportalsolesslikelytohavesymptomsofPTSD.

§ Anxietyisatveryhighlevelsamongtheworkforce.Thosewithsevereandextremelysevereanxietycomprisearound40%ofthesampleinalljurisdictions.

§ Fatigueremainsamajorproblemformorethanhalfofallstaffineachjurisdiction,evenwhencontrollingforvariablessuchasage,gender,dependents,tenure,workhoursandshiftlength.Intervieweesreportpersistenthighfatigueacrossallgeographicalareas,affectingtheirabilitytoperformanddesiretostayintheserviceforthelongterm.

§ Around one in every five employees are seriously looking for another job. Employees’intentiontoquitishigherwhentheyviewthehumanresourcemanagement(HRM)systemasweak,andwhentheyareregularlyexposedtonaturaldisastersandphysicalassault.ThisfindinghighlightstheimportanceofbuildingastrongHRMsystemwhereemployeesareclearaboutthebehavioursthatareexpected–andrewarded–bytheorganisation.ThispointisreinforcedbyasignificantrelationshipbetweenHRMsystemstrengthandemployeefatigue.

§ The employee support systems in place in these organisations provide vital social andorganisational support for employees. Both formal and informal colleague support arefundamentalelementsofthesupportsystems.

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A lot of paramedics live, eat, sleep and breathe the job. So

their entire identity is wrapped up in being an ambo... I've been a paramedic for 25 or 26 years. I couldn't conceive of not being a

paramedic.

[Interview 5]

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roject Overview The two key aims of this research project was to betterunderstand how paramedics and support staff perceived thehumanresourcemanagementsystemintheirorganisationandhow the perception of these systems influence employees’individualoutcomes,particularlypsychologicalhealthandwell-being (includingPostTraumaticStressDisorderorPTSD).With

theknowledgegainedfromthisproject,guidancecanbedevelopedforpractitionersand policy makers on optimal approaches towards human resource management(HRM)andsupportinemergencyserviceorganisations.

Datawerecollectedprimarilythroughtwophonesurveysandface-to-faceinterviewsinQueensland,SouthAustraliaand theNorthernTerritory. Surveyswereconductedover thephonebycall centreemployeesengagedbytheunionduringthesecondhalfof2017.Thefirstsurvey(Study1)tookonaverage45minutestoadminister,andthesecond(Study2)tookapproximately20minutes.

Study1 askedquestions aboutemployees’ experiencesofwork andStudy2explored lifestyle andhealthfactors.Surveyquestionsweredevelopedfromvalidatedscalesrelatingtotraumaexposure,supporteffectiveness,coping,modifiablelifestyles,resilience,futureemploymentintentions,healthstatusandhumanresourcemanagementsystems.Intotal,1216usablesurveyswereobtainedfromthetwostudies.Datawasanalysedusinggeneralizedlinearmodelling.Questionnaireswithmorethanhalfofthedatamissingwereexcludedfromdataanalysis.ThenumberofuseablesurveycompletionsforeachjurisdictionandeachsurveyareinTable1.

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SurveyOne SurveyTwo Matchedcases

Queensland 373 308 281

SouthAustralia 273 197 118

NorthernTerritory 40 25 23

Total 686 530 492

Table1SurveyCompletions

Semi-structured interviews,were conductedprimarily inpersonandwitha smallnumberover thephone, for the purpose of better understanding the key issues and experiences of participants.Seventy-twointerviewswereconductedwithparticipantswhoincludedemergencydispatchofficers,patienttransportofficers,paramedics,frontlinemanagers,middlemanagement,uppermanagement,andseniorleadership.Datahasbeencodedandanalysedusingatextanalysisprogram,NVivo,andourfindingsarebasedonthemesinthescholarlyresearch.

This report is presented as follows. Section One presents findings on the health andwellbeing ofparamedics,focusingpredominantlyonthedatafromthesurvey.SectionTwoconsidersthesystemsandsupportavailableforparamedics,andcombinessurveydatawiththemesfrominterviewanalysis.SectionThreefocusesonsixkeyareaswhereweprovidemorein-depthdiscussionoftopicsarisingfrom the project, including: the ‘high-reliability’ management approach; resilience training; mealbreaks; the changing workforce; paramedic career directions; and, considerations relating tocommunicationscentres.Insum,thisreportprovidesacurrentsnapshotofthehealthandwellbeingof the Australian emergency services workforce, and highlights key issues in the management ofemployeesandthesystemsthatarecriticaltotheircontinuingsupport.

This Summary Report is to be read in conjunction with the Companion Report which includesdescriptivestatisticsanddetailedstatisticalmodellinginformation.

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SECTION 1 THE HEALTH AND WELLBEING OF PARAMEDICS

More than $9 billion is spent onmental health in Australia annually, a figure thatcontinuestogroweachyear (Australian InstituteofHealthandWelfare,2018)andpresents growing concern for employers of individuals who work in stressfulenvironments or are exposed to trauma in their workplace. The nature of workperformed by emergency service personnel and in particular frontline paramedics,

means they operate in a highstress environment, and areexposed to traumatic andextreme events on a regularbasis.

Previous research demonstrateschronicexposuretotraumaticeventsincreasestheriskofpsychological illhealth,andassociatedmentalhealthproblems including PTSD (Grant,Dutton,&Rosso,2008;Huizinketal.,

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2006).StudiesofPTSDinemergencyrespondersreportthatthosesufferingfromassociatedsymptomsisalmostdoublethelifetimeprevalenceforthegeneralpopulation(AustralianInstituteofHealthandWelfare, 2018; Skogstad et al., 2013). Given that exposure to traumatic events is unavoidable foremergency service workers, the consequences for not effectively controlling this hazard can bedevastating on an individual level and have accumulative consequences for the employingorganisation. In this section,we consider the health andwellbeing effects of trauma exposure onemergency services workers, including PTSD, stress, anxiety, depression, general mental health,physicalhealth,fatigue,workabilityandintentiontoquit.

1.1. POST-TRAUMATICSTRESSDISORDERItisdifficulttoobtainaccuratecostsaboutmentalhealthingeneral,andparticularlyPTSD,asmanyoftheestimatesareeithermorethanadecadeold,orfrommilitaryorganisations.EstimatesrangefromUS$4,000toUS$20,000perpersonperyear(Ferryetal.,2015;Ivanovaetal.,2011).Muchofthiscost(anestimated80%)comesintheformof lost productivity and ‘presenteeism’ in theworkplace,with the remaindercomprisedofmedicalexpensesassociatedwithimmediateandongoingphysicalandmentalhealth requirements (Ferryetal., 2015). There isa longhistoryof researchdemonstratingaspill-overeffectfromworkintonon-worklifeandalthoughresearchonthespill-overontheparamedicprofessionis limited, it is likelythatfamiliesareaffectedbyaparamedic’sworkexperiences(Hill,2014).Hence,asidefromthehumansuffering, there is also an important financial and social burden for individuals,organisationsandsociety.

Wemeasured levels of PTSDusing thePCL-5measure,whichwasdevelopedbasedon theDSM-5criteria for PTSD (for further discussion of this measure see Appendix A). Using this measure,participantswereaskedtokeepthemoststressfulexperienceinmind,andrate(onascale0to4)theextenttowhichshe/hehasbeenbotheredbythatspecificexperienceinthepastmonth.Asumofallitemsprovidespossibletotalscoresof0-80.AprovisionalPTSDdiagnosiscanbemadewhenthetotalscoreofPCL-5is33andabove(Bovinetal.,2016).

OurresultsindicateaprovisionalPTSDdiagnosiscanbemadefor10%ofQueenslandand8.5%ofSouthAustralianstaff1.Inrawnumbersthisextrapolates(approximately)inthefullpopulationto350and90individualsin

1WewereunabletodetermineanumberfromtheNorthernTerritorysampleduetosmallsamplesize.

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eachstaterespectively.Anadditional6.6%and4%ineachstatehadaPLC-5scoreof25-32,whichmeansaround250additionalparticipantsin Queensland sample and 40 additional participants from SouthAustraliasampleareclosetothecut-offscoresforaprovisionalPTSDdiagnosisandassuchareindangerofdevelopingPTSD.

Thesefiguresarelowcomparedwithfindingsfrompreviousstudiesofemergencyorworkersorparamedics(Bennettetal.,2005;Clohessy&Ehlers,1999)and indeed fromourpilot study.However, it shouldbenotedthatthestandardcriteriausedbyprofessionalsforPTSDchangedconsiderably between the pilot survey of this research program andStudy 1 with the newest edition of the American PsychiatricAssociation’s (APA) Diagnostic and Statistical Manual of MentalDisorders(DSM-5)comingintouse(fordiscussionofthispointandhowitislikelytohaveaffectedthisstudyandtheambulancecontextmorebroadly,seeAppendixA).

AnumberofvariablessignificantlypredictthefrequencyofexperiencingPTSD symptoms. For example, length of tenure was associated withfrequency of experiencing PTSD symptoms. Respondents with 16-25years’experienceintheservicereportedexperiencingmoresymptomsofPTSDthanallothers.Itislikelythisrelationshipisinfluencedbytheincreased instances of exposure to traumatic incidents. The surveyfoundhigherratesoftraumaexposure,andincreasedtypesoftraumaexposure (e.g. natural disasters, motor vehicle accidents) were alsoassociatedwithhigherincidenceofPTSDsymptoms.Further,individualsfrequently exposed to toxic substances; those frequently exposed tocombat;andthosewhofeeltheyhavecausedharmtoothers;werealsomorelikelytoexperiencesymptomsofPTSD.Fromourdata,fatigueisthestrongestpredictorofindividualsexperiencingPTSDsymptomsandothernegativeemployeeoutcomes,andisexploredfurtherinsection1.4Fatigue).

Socialsupportofcolleagues,friends,familyandtheimmediatemanagerwasfoundtohaveanegativerelationshiptothefrequencyindividualsexperiencePTSDsymptoms.ThismeansthatthosewhohadmoresocialsupportwerelesslikelytohaveaprovisionalPTSDdiagnosisandfewerPTSD symptoms. Participantswho report feeling ‘somewhat’ to ’verymuch’supportedbysupervisorswereleastlikelytohaveaprovisionaldiagnosis of PTSD. This finding highlights the importance of socialsupportingeneral,andthatcolleaguesupportandsupportfromfamily

Respondentswith16-25years’experience

reportedmoresymptomsofPTSD

Fatigueisperhapsthestrongest

predictorofPTSD

Thosewithmoresocialsupport

werelesslikelytohavePTSDsymptoms

PREDICTORS OF PTSD

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and friends can be important to psychological ill health andminimising the prevalence of PTSD inemergencyservices(forfurtherdiscussionofthesepointsseesection2.2EmployeeSupport).

Thedirectionof theserelationships isnotdeterminable fromthedata,however the importanceofsupportbothatworkandathomecannotbeoverstated.Giventhatexposuretopotentialtraumaislargelyunavoidableformostparamedics,reducingfatigueandensuringhighlevelsofsupervisorandcolleague support can be valuable to minimise the likelihood of individuals suffering from thedebilitatingeffectsofPTSD.

AlthoughfrequencywithwhichanindividualexperiencesPTSDsymptomsareofconcern,scoresonthisscalealsopredictedorganisationalfactors.Forexample,employeesreportingmorefrequencyofexperiencingPTSDsymptomsalsoreportedhigherlevelsofintentiontoquitandlowerworkability.Theseoutcomesimpactthecapacityforemployeestocontinuetheircareerinthemediumandlongerterm.Moredetailedinformation(suchasthestatisticalrelationships)aboutthepredictivemodellingforPTSD,isprovidedintheCompanionReport.

1.2. STRESS,ANXIETY,DEPRESSIONANDGENERALMENTALHEALTH

Toexaminedepression,anxiety,andstress,theDepression,AnxietyandStressScale(DASS)(Henry&Crawford,2005)wasused.Thisscalehas21self-reportLikertscaleitems with three subscales (depression, anxiety and stress). For depression, totalscoresof0-3indicatenormal,4-6formilddepression,7-10formoderatedepression,11-13 for severe depression, and 14 ormore for extremely severe depression. Foranxiety, total scoresof0-3 indicatenormal, 4-5 formild, 6-7 formoderate,8-9 forsevere,and10ormoreforextremelysevere.Forstress,totalscoresof0-7indicatenormal, 8-9 for mild, 10-12 for moderate, 13-16 for severe, and 17 or more forextremelysevere.

Around17%ofQueenslandandSouthAustralianparticipantsreturnedsurveysthatindicatedsevereorextremelyseveredepression,whileNorthernTerritoryparticipantsreported12%atthesevereandextremelyseverelevels.However,forNorthernTerritoryalmost40%ofthesamplereportedmoderatedepression,comparedwithonlyaround20%inQueenslandandSouthAustralia.

Oursamplealsoincludedevidenceofsevereandextremelysevereanxietyreachingalmost40%inallthreejurisdictions.Whenweincludemoderatelevelsofanxiety,theSouthAustralianandNorthernTerritorysampleresultsballoonoutto55%and64%respectively,withQueenslandslightlylowerataround50%. Interestinglythough,whiledepressionandanxietyarehigh,wefoundreportedstresslevelsinthemoderatetoextremerangeonlyreached10%inallthreejurisdictions.

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Thisdisconnectioncanbeexplainedbyidentifyingstressasacognitiveresponsetoacurrentthreatthatwillnolongerexistwhenthethreathasgone.This contrasts with anxiety which is apsychological stress response that remains foralong period. This response may not fade evenwhendistancedfromthestressor.Giventhatthesurveywas not administered at or immediatelyfollowing a stressful work situation this canexplain why stress was not high, althoughelevated levels of anxiety remained as aprolonged psychological consequence of paststressors.

Arelationshipbetweenshiftlengthanddepressionwasevidentintheresultswithparticipantsworkinglonger shifts more likely to report depressive symptoms. As would be expected, employees whoreportedalcohol abuseorotherdrugabusealso reportedhigher levelsof depressionandanxiety.Again,whilethedirectionofthisrelationshipcannotbedeterminedwithourdata,otherresearchhasshownthoseusingmaladaptivecopingstrategiesweremore likelytodevelopPTSDanddepression(seefordiscussion,Skeffington,Rees,&Mazzucchelli,2017).

Mental healthwas also examined as one component of the Short Form12 (also used tomeasurephysicalhealth,describedinthefollowingsection),whichproducesascorefrom1-100(lowtohigh).Thementalhealthcomponentexamines itemssuchassocial functioningandrole limitationduetomentalhealthissues.Acrossthesample,thementalhealthscoreforallstateswasaround50,evenwhencontrollingfordifferencesbetweensamples,andthisscoreisconsistentwiththeaverageforthegeneralpopulation(Ware,Kosinski,Turner-Bowker,&Gandeck,2002).

Findingsrevealfactorslikelytoimproveanindividual’smentalhealthscore.Forinstance,individualswho report more resilience also report higher mental health. Similar to anxiety and depression,individuals who reported hazardous alcohol drinking and other types of maladaptive coping, alsoreportedlowermentalhealthscores.

“OURSAMPLEALSOINCLUDEDEVIDENCEOFSEVEREANDEXTREMELYSEVEREANXIETYREACHINGALMOST40%INALLTHREEJURISDICTIONS.WHENWEINCLUDEMODERATELEVELSOFANXIETY,THESOUTHAUSTRALIANANDNORTHERNTERRITORYSAMPLERESULTSBALLOONOUTTO55%AND64%RESPECTIVELY,WITHQUEENSLANDSLIGHTLYLOWERATAROUND50%.”

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1.3. PHYSICALHEALTHMaintenanceofoptimumphysicalhealthoverthecourseofacareerisnecessaryforambulanceemployeestoprovidethelevelofservicerequired.Tomeasureemployees’physicalhealth,thephysicalcomponentoftheShortForm12wasused,producingascoreof1-100.Thiscomponentconsidersitemsincludingphysicalfunctioning,healthproblems,bodilypainandvitality.

Usingthisscale,thestudyfoundgeneralphysicalhealthwasverysimilarbetweenparticipantswithmeanscores ineach jurisdictionat50outof100,consistentwiththeaverage level forthegeneralpopulation(Wareetal.,2002).Surveyresultsindicateincreasedfatigueandhigherincidenceoftraumaexposure(bothfrequencyandquantity)woulddecreasephysicalhealthamongsttheworkforce.

1.4. FATIGUEFatigueisacommonareaofconcernamongemergencyserviceworkers.Onestudyconductedamongemergencymedicalservicesworkersfoundthat55%experiencedfatigue (Patterson, Suffoletto, Kupas, Weaver, & Hostler, 2010). Similarly, a studyconductedonruralandregionalambulancepersonnelinAustraliafoundmorethanone thirdofparticipantsexperienced severe fatigueatworkandanotherone fifthreportedmildfatigue(Pyper&Paterson,2016).

When examining research that relates to outcomes of fatigue on the health, wellbeing andperformance of paramedics, almost nine out of ten emergency service workers believed fatigueaffected theirwork performance (Sofianopoulos,Williams, Archer,& Thompson, 2011). Pyper andPaterson(2016) foundparamedicsbelievedfatigue increasedtheir likelihoodofmakingmedicationerrors,havedrivingaccidents,or ‘nearlycrash’dueto fallingasleepwhiledriving.Equally, reducedreaction speed, reduced decisionmaking ability, and concentration were all the result of fatigue.Longitudinalresearchshowsanincreaseinfatigueovertimeamongambulancepersonnelincreasessickleaveandplacesthematriskofdisability(vanderPloeg&Kleber,2003).

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In this project we used the Fatigue Assessment Scale (de Vries,Michielsen,VanHeck,&Drent,2004)tomeasurefatigue.Thisscalehas10 self-report items asking about participants’ fatigue levels. Totalscores range from 10 to 50 with a higher score indicating greaterfatigue. It is no surprise shift workers performing long hours andemotionally draining work will feel fatigued. Our figures indicatefatigue remains a problem for more than half of staff in eachjurisdiction. The findings are consistent even when controlling fordifferences in age, gender, dependents, nightshifts worked, worklocation,workinghours,shiftlengthandlengthoftenure.

Inourstatisticalmodelling, fatigue ismostapparent inpeopleuptothe age of 40 and more apparent in people who have frequentexposuretolifethreateningillnessorinjury.PeoplewhorankhighlyonPTSD scores are more likely to be fatigued. Conversely whenemployees perceive theHRM systems to be strong (see section 2.1HumanResourceManagementSystemStrength)andhavehighlevelsofsocialsupport, their fatiguescoresare lower.This is importanttonotegivenhowrelevantfatigueisasapredictorofnegativeemployeeoutcomes.

To measure resilience, The Connor–Davidson Resilience Scale (CD-RISC) (Campbell-Sills&Stein,2007)wasused.Thisscalehas10self-reportitems,askingtheparticipantabouttheextenttowhichtheyareable to recover from, or adapt positively to, ‘change, personalproblems, illness,pressure,failure,andpainfulfeelings’(Campbell&Stein, 2007, p. 1026). The sum of the scale provides a total scoreranging from 0-40, with higher scores indicating greater levels ofperceivedresilience.

Akeycopingmechanismattheindividuallevelisresilience(resilienceappearsasapredictingvariableforfouroutoffivehealthoutcomes).What is clear from our modelling is that while adaptive copingmechanismscanassistwithresilience,fatigueandmaladaptivecopinghave a negative relationship with resilience. Equally, levels andexperiences of insomnia will negatively predict an individual’sresilience levels, that is, those with insomnia will have reducedresilience.Organisational andwork related factors that relate to anindividual’sresilienceincludethenumberofhoursoneworks(thoseworkingmorethan36hoursscoredthelowestonresilience).

Findings on fatigue Fatigueremainsaproblemformorethanhalfofstaffineachjurisdiction.Fatigueismostapparentinpeopleuptotheageof40.WhenemployeesperceivetheHRMsystemstobestrongandhavehighlevelsofsocialsupport,theirfatiguescoresarelower.

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1.5. WORKABILITYANDINTENTIONTOQUIT

Byunderstandingthecapacityofemployeestocompletetasks,wecandefineactionsthatpreventdeteriorationandpromoteimprovementoftheirabilitytodotheirjobwell,andincreasetheirdesiretostaywiththeiremployer.Twomeasureswereusedinthisresearchtobetterunderstandthelikelihoodthatemployeeswillremainintheiremploymentwithcapacitytosuccessfullycompletetasksandresponsibilities.Thesemeasuresrelatetoworkabilityandintentiontoquit.

The average work ability score was 35,indicating moderate work ability. In thisenvironment, a moderate level of workability is lower than the employingorganisationswould be striving for as it isunlikely to result in individual longevity intheprofession.

‘Workability’isthebalancebetweenanemployee’sphysical,mentalhealthandsocialresourcesandtheirdemandsatwork.TheoriginsoftheWorkAbilityIndex(WAI)lieinresearchdesignedtoassesshowlongemployeesareabletoworkandtowhatextentbeingabletoworkdependsontheworkcontent and job demands (Ilmarinen, 2007). An assessment of work ability is helpful to assistunderstandingofhowtopromoteanindividual’s(andworkforce’s)capacitytocontinueworkingintheshort,mediumandlongterm.ThepossiblerangeofscoresoftheWAIarefrom7to49.Ascorelessthan 27 indicates poor work ability; from 28-36 ismoderate; 37-43 is good; and 38 and above isexcellent.

Inthisstudy,theaverageworkabilityscoreforparticipantswas35,indicatingrespondentsperceivedtheirworkabilityasmoderate.Inthisenvironment,amoderatelevelofworkabilityislowerthantheemployingorganisationswouldbestrivingforas it isunlikelytoresult in individual longevity intheprofession.InQueensland,51.9%ofparticipantsreportedtheirworkabilityaspoorormoderate.ThisiscomparablewithNorthernTerritory(50%),butnotashighasSouthAustralia(59%),suggestinganeedforinvestigationtopromoteimprovedworkability.

Qualitativedataprovideadeeperunderstandingofworkability,withmanyparamedicssuggestingtherolewouldlikelyleadtoburnoutandisnotsustainableoverthelongterm:

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Forme,Iwanttogetoutoftheambulanceservicebecausejustobjectively,Idon’tseemany50,60yearoldambosretiringwhohavehealthymarriages,areagoodweight,aregenuinelyhappypeople,andarestillthemselves.WhatIdoseearethesepartlyangry,overweight,somewhatunhappy…Iwanttogetoutbecausenotmanyambosrunthegauntletandcomeoutunscathed[Interview45].

Anumberofkeyfactorsthatinfluenceworkabilitywerehighlightedintheanalyses.Firstly,workabilitywasthelowestamongthoseworkinglessthan8hourspershift.Researchdemonstratesworkinglongerhoursreducesworkability(Mokarami,Mortazavi,Asgari,Choobineh,&Stallones,2017),hence,itispossiblethatrespondentshaveself-selectedtoworkshortershiftswherepossibletoindividuallyeliminateexposuretolongershifts.Inlinewithexpectations,thoseexposedtophysicalassaultandmoreinstancesof traumaexposurealsohada lowerworkabilityscore.FatigueandPTSDalsohadanegativeeffectonworkabilityamongrespondents.

Workabilityiscloselyrelatedtoanindividual’sintentiontoquitbutresults indicated they are conceptually distinct and thus warrantseparateattention.IntentiontoquitscoresareofgreatestconcernwithintheNorthernTerritorysample,with25%ofparticipantsindicatingtheyareseriouslylookingforanotherjobandwillbeunlikelytoremaininthatemploymentin5yearsfromthetimeofthesurvey.Incomparison,theQueenslandsampleshowed20%ofstaffwithanintentiontoquit,andaround15%oftheSouthAustraliansamplewereactivelyseekingalternativeemployment.

Severalfactorspredictanindividual’sintentiontoquitinthedata.Themorefrequentlyoneisexposedtonaturaldisastersandphysicalassaults,thegreatertheemployee’sintentiontoquit.Employeesinfulltimeemploymentaresignificantlylesslikelytoquitthanthoseinparttimeorcasualemploymentworking fewer than20hoursperweek.Some intervieweesexplainedthatemployeesworkingparttimehoursweredoing sowhile theyweredeveloping themselves inpreparation for anewcareeroutsidetheservice:

There'sadifferentphilosophynowthanwhenwestarted20,30oddyearsago…Nowpeoplearecoming inandseeing that it'sacompletelydifferentenvironment. It'ssuper-fatiguing,it'ssuper-busy,it'ssuper-confrontingandit'snotsomethingthatthiscurrentgenerationareseeingastheirlife-longcareer.They'reseeingitasa10to15yearcareer.Ireckonnearlyallofthepart-timersinmyregionoronthefringecountryregion are doing job share because they're forging out or have another career[Interview55].

Intentiontoquit isalsoinfluencedbytheHRMsystem–whenit isviewedasweakit increasesthelikelihood of employees leaving their organisation (Li, Frenkel, & Sanders, 2011). Accordingly, ourresultssuggestemployeeswhoperceivetheHRMsystemasstrongalsoreportlowerintentiontoquitinthenextfiveyears.Importantly,astrongHRMsystemisassociatedwithareducedintentiontoquit

“Idon’tseemany50,60yearoldambosretiringwhohavehealthymarriages,are

agoodweight,aregenuinelyhappypeople,andarestillthemselves.”

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particularly for those frequently exposed to physical assaults. It also appears thatwhen the socialsupportanindividualreceivesislow,theirintentiontoleaveincreases.Thesefindingsagainreiteratethecriticalnatureofsocialandformalsupportsystemsintheambulanceservice,whichwediscussindetailinsection2.2EmployeeSupport.

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SECTION 2 SYSTEMS AND SUPPORT FOR PARAMEDICS

2.1 HUMANRESOURCEMANAGEMENTSYSTEMSTRENGTH

TheHRM system refers to the practices, processes, philosophies and strategy thatassisttheorganisationtoachievegoalsviamanagementofitshumanresources.Theperceived strength of this system is important, as a strong system communicatesunambiguousmessagestoemployeesaboutbehavioursthatareexpected,valuedandrewardedbytheorganisation(Ostroff&Bowen,2016).

Bowen&Ostroff (2004)definea ‘strong’HRMsystemasone,whichhas: (1)distinctivenessofHRpractices (i.e. they are visible, understandable, legitimate and relevant to employees’ goals); (2)consistencyofHRpractices(i.e.theirpurposeispresentedinthesamewayandareinternallyaligned);and,(3)consensusaboutthepractices(i.e.thereisagreementamongpolicymakersabouttheneedforandpurposeofthepractices).Whenemployeesperceivethesystemtobestrong,thisfacilitatesa

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supporting climate whereby employees understand and enactexpectedbehavioursthatalignwiththeorganisationsgoals(Bowen&Ostroff, 2004)which thereby improvesperformance (Cunha&Cunha,2009).Researchhasalsopointedtorelationshipsbetweenstrong HRM and employee level outcomes, such as affectivecommitment(Sanders,Dorenbosch,&deReuver,2008),employeeworksatisfactionandintentiontoquit(Lietal.,2011).

Inthisstudy,perceivedHRMsystemstrengthwasidentifiedusingthemeasuredevelopedbyDelmotte,DeWinne,andSels (2012),which assigns a score in a possible range of 31-155. Based onpreviousresearch(seeforinstance,Cafferkey,Heffernan,Harney,Dundon,&Townsend,2018;Delmotteetal.,2012;Sanders&Yang,2016),scoresof62andlessareindicativeofemployeeperceptionsof aweakHR system. Scores of 93 and over suggest employeesperceiveastrongHRsystem.InQueenslandlessthanaquarterofrespondentsrankedthesystemasstrong(23%scoredthesystemhigherthan93),comparedwith16%inSouthAustraliaand10%intheNorthernTerritory.

One probable explanation for these differences is organisationalsize; larger organisations have greater access to resources, andemploy more HR professionals thus increasing the capacity todevelop and implement policy and communicate with staff. Asnoted,withincreasedHRMstrength,intentiontoquitdecreased.But perhaps more importantly for the safety and wellbeing ofemployees, strong HRM reduced fatigue significantly. Given theevidenceisclearregardingtheimportanceoffatigueonarangeofoutcomes for employees, this relationship needs furtherunderstandingandinvestigation.

A‘strong’HRMsystemhas:(1)DistinctivenessofHRpractices-theyarevisible,understandable,legitimateandrelevanttoemployees’goals(2)ConsistencyofHRpractices-theirpurposeispresentedinthesamewayandareinternallyaligned(3)Consensusaboutthepractices-thereisagreementamongpolicymakersabouttheneedforandpurposeofthepractices

STRONG HRM SYSTEMS

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2.2 EMPLOYEESUPPORT2.2.1 Formal systems of support Across the states and territory, significant consideration is directed toward developing robustformalised organisational support systems that build employee resilience and assist coping. Theseservices includetelephoneandface-to-facecounsellingservices,debriefing,educationandtraining,andthepeersupportprogram.ResponsesfromintervieweesindicatedanoverallpositiveperceptionofthesupportprogramsinQueenslandandSouthAustralia.

Therewasclearconsensusthatthecomponentsoftheprogramwereeffectiveindividuallyandfittedtogetherwellasacohesivesystem.Thefollowing intervieweecapturestheprocessthatfollowedacriticalincidentinSouthAustralia:

Onceanincidenthasreachedacertainpoint,there'sanautomatic[process],youhave-managersarecomingdowntodoadebrief,thecrew'sstooddown,theyallgobacktostationandtheyhavethatdebrief…Ididn'tfeelcompletelyreadytodownloadtothismanagerthatI'mgoingtohavetositinfrontofinfutureinterviews…Sothenextthing thathappened foruswaswegotaphonecall fromoneof -wehave threepsychologistsinthecitythatwecanaccessfourtimesayear.Sooneofthosegaveusacallthatnightandthatwasquitehelpful…Soboom,boom,boom!That'squiteagoodfoundation….Butthenwegotfollowupfromourteamleader.‘How'sitgoing?Everythingallright?’Justsoftly,softly[Interview35].

However,whenconsideringaspectsoftheworkoperationmorebroadly,therewasageneralsensethat aspects outside the formalised organisational support systems inhibit employees’ capacity orwillingnesstoaccessthissysteminrelationtosomeareasofconcernforthemoratcertaintimes.

Forexample, thepreviousquote suggests someemployeesbelieve thedebriefwith theirmanagercannot be sequestered from later interactions. In each jurisdiction therewas also some reticenceexpressed to engaging in honest conversations about psychological health for fear of it possiblyimpactingan individual’s careerprogression.These concernsareprohibiting some individuals fromseekingsupportwithinthesystem.Someemployeesindicatedtheysoughtpsychologicalsupportattheirownexpense,outsideoftheorganisation,toavoidthisconcern.Thisisakeyfindingrelatingtothecounsellingelementoftheformalsupportsystem.

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I feel likewe spenda lotofmoneyonour staffwelfare through thepeer supportprogramandourEAP,thepsychologistwhowehaveavailabletous.Butitseemsveryclosed… there's… psychologists thatwe're allowed to go and see. Now, if you'resomeonewhoisthinkingIalsoamapplyingforthispositionatthemomentandIthinkthispersonmightbeonthispanel,IthinkIjustwon'tgo.We'renotreallygivenotheroptions[Interview53].

Anothercorecomponentofthesupportsystemiseducationandtraining.Thistrainingisconductedtovaryingdegreeseachjurisdictionforindividualsandtoimprovemanagerialskillstoimproveemployeeresilienceandcoping.Asformaltertiaryqualificationsareneededforallemploymentasaparamedicacrossall jurisdictions inAustralianow it seemsreasonable toexpectsomeaspectsof this trainingwouldalsobedirectedtowardsmentalhealthandwell-being.

However,ourreviewofthecoursetopicsfortenuniversitiesacross Queensland, South Australia and the NorthernTerritoryofferingtheBachelorofParamedicSciencedegree,found only one university explicitly advertised a unit withsomecontentonunderstandingtheparamedic’sownmentalhealthinthecontextoftheworkenvironment.Withinthiscourseonlyone lecture isdedicatedtoexploring ‘ourownmentalhealthandcareoftheself,mentalhealthcontinuum’.As the Executive Manager of Priority One in Queenslandstates:

Someoftheuniversitiesdoalot[forstudents]aroundmentalhealth.Someofthemdoverylittle.Soit'sveryinconsistentacrossAustraliawhatuniversitiesofferinthatspace.Thisisconcerninggiventhatthemajorityofnewparamedicsdonothavetheleveloflifeexperienceoncecommonamongambulanceofficersindecadespast.

Pressureisthereforeplacedontheindividualandtheambulanceservicestobuildresilienceandcopingskills in-house on an ongoing basis. Some resilience training is incorporated into the inductionprograms.InSouthAustraliaandQueensland,ahalfdayprogramisprovidedbutthestructureofthesemaynotbeidentical.InSouthAustralia,theprogramisdescribedbyaparamedic:

Pre-education,Ithink,isabigthingwithintheorganisationandwerunaboutafourandahalfhoursessionwithallnewemployees.Managingpersonalstressesintheworkplaceisthesubject.It'sactuallyaunitofcompetencyunderthehealthtrainingpackage.We'vedevelopedourownpackage.Wedeliverit.Sowetalkaboutthingslikeshiftwork,theambulanceservice,cumulativestress,acutestress,thosetypeofstuffwithinthat.Wealsotalkaboutourpeersupportprogram[Interview32].

Thereissomesuggestion,however,fromSouthAustralianintervieweesthatamorecomprehensiveapproachwouldbeofbenefitintheinductionprocessandalsoongoingoverthecourseofacareer:

Onlyoneuniversityexplicitlyadvertisedaunitwithsomecontentonunderstandingthe

paramedic’sownmentalhealthinthecontextofthe

workenvironment.

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WhenIdidmyinternshiponlyfourandahalfyearsago,[theleadpsychologist]didcomeinandbasicallygaveusabitofachat.Butitwasnothinglikesuperindepth.Itwasreallyjustlikethesearesomesigns[ofstress]andifyouhaveanissuecallus[Interview41].

Thisextendstomanagersaswell:

OneofthethingsI'veoftenthoughtorwishedforwasasateamleaderthatwegetsomebasictrainingontraumacounselling…Whenwegettrainingit’s-trainingtimeissolimited,thefocusisinevitablyonclinicalthings…[Interview24].

WhileclinicaltraininginSouthAustraliaissophisticatedandgenerallywellresourced,feedbacksuchasthisfromintervieweesindicatesagapexistsintheprovisionofinitialandongoingtrainingintheformatordepthdesiredbyemployees.Paramedicsreportregularclinicaltrainingatastationlevelandexpressdesiretoalsoincludetrainingforresilienceandmentalhealthoftheemployees.

InQueensland,the‘FindingtheSilverLining’Programhasbeenintroducedaspartofthe inductionprocess,withsomepositivefeedbackfromemployees.Thisisafour-and-a-half-hourprogramwhereparticipantsareprovidedwithonlineandprintresourcesandmaterialtocompleteoverthefirst12-24weeksontheroad,andareflectivejournal.Asoneintervieweeexplains:

TheSilverLiningsworkbookisaseriesofactivitiesthatarelargelyself-reflective.Ittalksaboutsleeppatterns,work/lifebalance,copingmechanisms,howtorecognisestressorsandreactiontothestress…It’spurelyaself-reflectiveactivitybook.ButthatthenneedstobefollowedupwithamandatoryappointmentwithourPriorityOnepsychologist…attheendoftheactivity,andespeciallyaftertheappointmentwiththepsychologist,mostofthecommentsareverypositive.Itsortofseemstomakesenseoncethatloopisclosedwiththepsychologistappointment[Interview62].

Queenslandalsoconductaonedaymandatorytrainingprogramformanagers,supervisorsandactingsupervisors which focuses on Trauma and Resilience in theWorkplace. The program covers legalresponsibility forpsychologicalwellbeing,andother topics suchas critical incidents,PTSD,anxiety,depression and suicide.Over a periodof almost ten years theprogramappears to havepositivelyinfluencedthewaymanagersandsupervisorsinteractwithemployeesaroundpsychologicalwellness.ThisisreflectedinthefollowingcommentfromaPriorityOneleaderdescribinganexercisetheyhaveconductedinthemanagerialprogramsinceitsinception.

Wesaytothem,what'salltheworstthingsyoucouldsaywhen[paramedics]getbackorwhentheycomebacktothestation?Itusedtobethattherewaslotsofenergyintheroom.Peoplewouldberecountingwhathadbeensaidtotheminthepast.Therewouldbeawholeheapof things thatpeoplewouldcomeupwith. Interestingly, Ireallysawacontrastlastyear.Thesamescenarios.Whenyouaskthemwhat'sallthethings that would be helpful, the room would go quiet and you wouldn’t hearanything.Butlastyearitwastheoppositewayaround.ItstruckmebecauseitwasthebiggestcontrastI'veseenaroundagroupofmanagers.Allthe‘worstthings’,they

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wereactually-theroomwentquiet.Theywerehavingtroubletryingtothinkofthings!And‘whatareallthehelpfulthings?’Theroomgotactiveandtheywere-theycameupwithloadsofthings[Interview65].

Asthequotedemonstrates,thereisanemphasisondeliveringpracticalskillstohelpmanagersconductpositiveinteractionsaboutmentalhealthandwellnesswiththeiremployees.Developmentofsimilarskillsamongemployeeswouldenablethemtoprovidebettersupporttotheirpeerswho our research suggests are a primary source of informal support.Some managers also felt that the training for managers, whileworthwhile,neededtobeextended:

Sincewe'vebeendoingthetrainingwenowgetlotsofmanagersthatringusupandgolook,I'mnotsurewhattodowiththis,orthecrew'sjustbeentothisterriblejob.Alotofthetimewe'llbesaying, have you rung the crew and seen how they're going?Sometimesit’sabouttalkingthemthroughthatbecausethey'rewanting to do the right thing andwanting to get us involved[Interview65].

2.2.2 Peer support program The peer support program is well established across Queensland andSouth Australia, and to a lesser degree the Northern Territory. Ourresearch shows this program is generally well received by employeesalthough there are operational pressures that mean people aresometimesunabletoaccesstheprograminatimelymanner.Specifically,feedbackrelatestothetimeframeinwhichindividualsarecontactedandthemeansofcommunication.

Firstly, someparamedicswould likemore controloverwhenandhowtheyarecontacted.ForexampletheperiodoftimebetweenanincidentoccurringandcontactfromaPSOwasatopicofmixedfeelings.WhilesomeintervieweesprefertimetoprocesstraumabeforespeakingaboutitwithaPSO,othersarecriticalofthecurrentapproachastheywouldlikecontactsooner.Thefollowingquotessummarisetheseperspectivesfromboththeparamedicandemergencydispatchperspectives:

“Over24hourslateryougetaphonecallwhenI'msittingonthecoucheating

dinner.Icouldn'thangupquickenough.”

“Thepurpose…it’stobeabletocatchpeopleinthemoment,likejustafterthey’vetakenatriple0call,not10to12hourslater.”

PEER SUPPORT

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I'vehadacallonceoveraday later -youknow,youdoa job in themorning, thefollowingnightathomesittingonthecouchthephone'sgoing.Oh,it'ssuchandsuchfrompeersupport.I'mlike,‘whatareyoucallingmefor?’Oh,inregardto-I'mlikeareyoufriggingkiddingme?Itwaslike-itwasaslapinthefacebecauseitwasasignificantjobthedaybeforeinthemorningbutover24hourslateryougetaphonecallwhen I'm sittingon the coucheatingdinner. I couldn't hangupquick enough[Interview43].

Iwoulddopeersupportforpeopleonadifferentteam.So,I’dbeonadayoffandgetaphonecallsaying,“yepthisperson’sondayshift.They’vejusttakenabadtriple0call.Canyouspeaktothem?”Iwouldhavetowaituntiltheyhadfinishedworkat7:00pmandthencallthem,orIwouldfinisha12-hourshiftandthenhavetogohomeandspendanhourortwoonthephonetosomeoneafterwards.SoIdon’tfeellike–thepurposeofwhatthatprogrammeismeantfor,it’stobeabletocatchpeopleinthemoment, like just after they’ve taken a triple 0 call, not 10 to 12 hours later[Interview30].

Thereisconsiderableresearchonthetimingofcontactpost-trauma;thisresearchisinconsistentandrarely straightforwardwithmanydifferencesbasedon individualpreferences. Itmaybehelpful toensureindividualsarenotifiedimmediatelywhentheyaretaggedashavingattendedadifficultjob,toacknowledgetheemployeemightbeinavulnerablestate.Thisallowstheorganisationtorespondorinteract inaway thatbest suits the individual’spreferences for support, thusallowing themmoreflexibilitytotailorthesupportmechanismtomeettheirpreferencesforcontacttypeandtiming.Thefollowingintervieweeprovidesadetailedsuggestion:

Ithinkweneedtoempowerpeopletousetheprogramandnotnecessarilyenforcetheprogramonpeople.“Hi,thisisDougdoingapeersupportcall.”“I’mfine,thanks.Thanksforthephonecall.Appreciateit.Seeyoulater.”Isthattherightway?Ithinkwe need to actually now start talking to our staff and saying,what type of peersupportdoyouwant?Ithinkthat'swherewecouldusetechnologytoouradvantage.So,youcouldgenerateanautomaticmessagegoingout.Soassoonaspeersupportisactivated,bang,“hey,Doug,peersupport'sbeenactivated.Doyouneedtospeaktosomebodynow?(a)No?(b)Yes.”Bang,itfiresbacktothepersonwho'sdoingthepeersupportactivation. Peersupport requirednow,orwhatever terminologyyouwanttouse,foracase.Weringin,wegetthedetails.Hey,theyneedcontactnow.Peersupportrequiredforajob.Ringin[Interview32].

Somesuggestanauto-generatedorpersonalisedtextmessageverysoonafteracriticalincidentoccurswouldsuitthembetter.SuchanapproachcaterstoasubsetofemployeeswhoindicatedtheydonotengagewithPSOs,butthecontactisstillimportant.Forthissubsetofemployees,itisnotalwaystwo-waycommunicationthatiskey,butacknowledgementofthedifficultjobtheyhaveattended:

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Igenerallywouldn't[engagewithaPSO],Iveryrarelyengagewiththembeyond,“I'mfine,thanksverymuchforthecall,IappreciatethecallandI'llgetbacktoyouifI'mhavinganytrouble.”ButIknowIfeelbetterthatsomebodycares,thatCommsrecognisedthatIhadtodosomethingdifficult,Ikindoffeelgladthatsomebodyhasacknowledgedthat[Interview7].

Whileforsomeemployeesitisthetimingofinitialcontactthatisacriticalfeatureofthepeersupportservice,forothersitistherecognitioninherentinthatcontactthatismoreimportant.Hence,forsome(butnotall)people,PSOcontactmayhavethesameeffectiveness inadifferent formatsuchasaninitialtextmessagewhichgivestheemployeethecontrolofwhetherandhowtheychoosetorespondtosupport.Theuseoftextmessage–althoughitcanbeviewedasimpersonal–doesgivetheemployeemorediscretiontomakecontactatatimethattheycanensuretheyareabletotalkprivatelyandwhentheyareready.ThefollowingparamedicdiscussesthistechniqueasappliedbyaPSO:

She'llsendyouaverygentletextandshe'llfollowitupinaweek'stime…IfsomeoneringsmeandwantstotalkaboutaparticularthingandI'mnotready,Iwon'tanswerthephoneorIwon'ttalkabout.It'slikeyouknow,I'dratherhaveafacetoface.ButIjustliketheway[aPSO]usessocialmediaratherthanthenormalprocessofpeersupportwhichisaphonecall…You'rekindofputonthespot.Yourpartnerissittingthere.It'sverycold.It'salmostclinical…SowhatIlikeaboutthetextsisshe'susingsocialmediatojustgohereifyouneedme,ifyouwantto-andsometimes-that'stheonlytimeI'veactuallyreactedtoaPSOandtextedback,youknow,actuallyitwasanawfuljob[Interview45].

2.2.3 Colleagues and family Accordingtothesurveydata,workcolleaguesandfamilyaretwomainsourcesofsocialsupportforemergencyserviceworkers.Around80%ofemployees inQueenslandandSouthAustraliareportedfeeling‘verymuch’supportedbytheirfamilyandnon-workfriends.Conversely,lessthanfivepercentofemployeesinbothstatesreportedfeeling‘notatall’or‘alittlebit’supportedbyfamilyandfriends,comparedtoaroundoneinfivereportingthesameabouttheirfrontlinemanager.PerceivedsocialsupportfromcolleagueswassimilarlyhighinQueensland(62%feel‘verymuch’support)andSouthAustralia (70%) andourqualitative research is complementary to these survey findings. Interviewsindicate formanyparticipants, colleagues, family and friends are themain andoftenonly supportavailable.Giventhecentralityofthesegroupsasprovidersofthemajorityofsocialsupportinallcases,itisofinteresttoexplorehowbesttofacilitateandimprovethissupportrelationship.

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Asthefollowingintervieweesuggests,a‘well-educatedworkforce’isnecessary,andtheoverwhelmingfeedbackfromintervieweeswas that further traininganddevelopmentonresilience,copingandsocialsupportwouldbeofgreatvalue.

[Peer support] seems to be as effective, if not moreeffective, than all the other interventions. I mean thewhole suite of them should be available, but a well-educatedworkforce,whoknowhowtodebriefeachotherwithout being invasive or nosey or judgmental, would

probablyhelpagreatdeal…howtorecognisethesigns,andactuallyifthey'retaughtabout the signs and symptoms in themselves, they'll know how to recognise it insomebodyelseanyway,justbydefault.So,destigmatising,encouragingpeopletoputtheirhandupiftheyfeelunwellornotdealingwithsomething,andworkmateswhospotwhere someonemightbe struggling.Andgoback to the family,because thefamilyobservesomeonefirsthandtoo[Interview58].

Colleaguesupportisfundamentalforassistingcopinginemployeesexposedtocriticalincidentstress(Oginska-Bulik, 2015).While the current scopeof training centres on self-care, caring for others isanotherclearpathwaytoofferdevelopedtrainingprograms.Identificationofsignsandsymptomsofstress-relatedmental illness inone’scolleagues,andhowtorespondandprovidesupport to thosesufferingwouldbebeneficial in theworkplace. Extending the current trainingprograms to includesessions available for family members, or simply offering educational materials to the families ofemployeesthatmayguidetheminprovidingeffectivesupport,islikelytobebeneficial.

Aspreviouslymentioned,thesetwosupportgroups–familyandcolleagues–providedifferentformsof support according to the employees interviewed. Colleagues are considered instrumental forreplayingacaseandconsideringthetechnicalaspectsofwhatoccurred.

You might do a very high stressful job, okay you might do a case that's verychallenging,youknow, theguy in thecarburnt,andyouspendquitea fewhoursdoingthatcase…Allyoureallywanttodoisspeaktoyourpeers,speaktosomeoneandgowellwedidthisjob.It'snotsomuchacaseallthetimeofohIfeelstressedorIdon’tthinkI'memotionallyI’mchallengedwithit.It'smoreof…theclinicalpathwayI went down. You try to talk it over with someone to go over how you wentprofessionally[Interview34].

Familyplayadifferentroleandarenotalwaysseenasasuitablesoundingboardtodiscussdifficultcases;colleaguesaregenerallyseenascriticalforthisaspectofsupport:

Youcan'tgohomeandtellpeople,Ihadababydietoday.Youjustcan'ttellthattomost people, they'd be devastated. Then they become needy, then they needattention and they're upset and they want to know what happened, and whathappens to the parents,what's going to happen next? You're like, I told you this

“YOU'RE LIKE, I TOLDYOUTHIS BECAUSE I WANTEDTOUNLOADANDNOWI'MMINDING YOU. SO YOUJUST DON'T END UPTELLINGPEOPLE.”

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becauseIwantedtounloadandnowI'mmindingyou.Soyoujustdon'tenduptellingpeople[Interview8].

Thisparamediccontinuestoexplain:

Usually if I go home in a badmoodor I'm irritable over something or upset oversomething,it'susuallynotthepatientcarekindofsideofitanymore.It'susuallyaproblemwithmanagement…Youknow,somethingelse,which iseasytogohomeandrantabout,andyoucanranttoanybodyaboutthat,youcantellthegirlintheshopandthey'reonyourside.Butgoinghome,youcan'tgohomeandtellpeople,Ihad a baby die today, you just can't tell that to most people, they'd bedevastated.Thentheybecomeneedy,thentheyneedattentionandthey'reupsetandtheywanttoknowwhathappened,andwhathappenstotheparents,what'sgoingtohappennext?You'relike,ItoldyouthisbecauseIwantedtounloadandnowI'mmindingyou.Soyoujustdon'tenduptellingpeople…WhenIwasnewinthejob,IwasverydependentonthecolleaguesthatIhadtrainedwithandthepeopleIwasworkingcloselywith.Wehadaverystrongnetwork,wewerenearlyallinour20s,wesocialisedtogetheralot,andwedidalotofwork-relateddebriefinganddrinkingandsocialisingtogether.Thatwasreallyimportantatthetime.Idon'tknowthatIknowwhatIwouldhavedoneotherwise[Interview8].

Thedifficultyassociatedwith colleague supporthowever is that thehighworkloadexperiencedbymanyemployees,particularlyinthemetroareas,doesnotprovidetheenvironmentfortherequiredinteractions.Thereisverylimiteddowntimebetweencases,andcanbeagreatdealofinconsistencybetween thepeers rosteredon in the samevehicle. In larger stations, this can lead todifficulty informinglastingrelationshipsbetweencolleagues.

There'snochancetodefuseafterajobbecausethey'rebouncingyoufromjobtojob,younevergetthechancetoprocesswhatjusthappenedbecauseyou'renowontothenext event. That never happened years ago, we were a very different service[Interview11].

2.2.4 Frontline managers Although FLMs can provide a great resource for employees, poorly skilled FLMs can create greatproblemsintheworkplace.Wemeasuredsupervisorsupportasoneelementofoverall‘socialsupport’(thesefindingsarediscussedinmoredetailintheCompanionReport).Tomeasuresocialsupport,theSocialSupportScalewasused(Caplan,1975).Thisscalehas12self-reportitemsdividinginto3majorsubscales(supportfromsupervisor,supportfromco-workers,andsupportfromfamilyandfriends).Thescaleasksparticipantstoratetheextenttowhichshe/hehassupportfromthesethreesourcesofsupport.Higherscoresarerelatedtotheemployeefeelingmoresupported.

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Employees’response Queensland SouthAustralia

NorthernTerritory

Supervisors’support

Notatall/alittlebit 21% 17% 20%

Somewhat 29% 26% 40%

Verymuch 50% 57% 40%

Table2SupervisorSupportforEmployees

AsTable2demonstrates,aroundhalfofemployeesperceiveahighdegreeofsocialsupportfromtheirFLM,andtheremainder feelonlysomewhatornotatall supported.Comparedtopeerand familysupport(exploredfurtherintheCompanionReport),FLMsupportwasperceivedbyemployeestobeloweroverall.Thesefindingsareinlinewithotherauthorswhosuggestemployeesperceive‘supportfrom co-workers, compared to support from supervisors, has greater importance’ (Oginska-Bulik,2015).Whilepeersupporthasbeenfoundtoaidthepost-traumarecoveryprocess,someresearchhasindicated FLM support is comparatively non-significant (Somville,DeGucht,&Maes, 2016). In ourstudy,however,therewerepositiveoutcomesassociatedwithsupervisorsupport;participantswhoreported moderate to high support from their supervisors were significantly less likely to have aprovisionaldiagnosisofPTSDthanthosethatreceivednoorlittlesupportfromtheirsupervisors.

Analysis indicates a range of barriers prevent FLMs from providing the high quality and effectivesupporttoemployeestheywanttoprovideandareaskedtoprovidebythepeoplewhoreporttothem.Asonemanagerdescribes:

Theintentmayneverbeforteamleaderstobethefirstpointofcallforthattraumacounselling,theyjustare.That'swhopeoplegoto[Interview24].

Intervieweesindicatetherearefactorsspecifictotheworkplaceandworkenvironmentthat inhibitemployeesandFLMsfromfosteringagoodsupportrelationship. Inallcases–butespecially inthelarger state of Queensland (both geographically and number of employees), employees indicatedphysical proximity, time restrictions, and workload restraints were the three major obstacles toeffectivesupervisorsupportintheworkenvironment.TherearecomplexitiesexperiencedbyFLMsindifferentgeographicalareas,particularlyassociatedwiththephysicalproximitybetweenmanagerandemployee.Despitethedifferencesbetweenruralandmetropolitanstations,lackofstaffcontactwasstillacommontheme:

I’ve relievedas supervisors in various rolesbut I think the frustration theyhave isaccess to the staff… So there’s frustrations from both sides because we get noguidance… So you’re not getting the constant interactionwith your supervisor to

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chewthefatandresolveissuesuntiltheygetbigger.It’sanaccessthing[Interview2].

Alongsidethisfactor,thereweresomeinhibitionsabouttheprivacyof conversations where support was sought from FLMs. As oneparamedicstated,“There'snotrustthatyouwillgetunderstanding,compassion,supportorconfidentiality.Noneofthoseisguaranteed.”It may well be that this is a historical perception among someemployeesbasedonpastincidents.Intervieweesindicated“noteverymanager,butdefinitelysomemanagers,willturnonyouiftheyknowyouarehavingtrouble.”Hence,thepreferencetoseeksupportfrompeersorfamilywasdeemedasaferandmoreconfidentialsourceformanyindividuals.

There was strong qualitative evidence in the data that the majorobstacle to quality support relationships between employees andFLMs across the three cases was a lack of managerial training,particularly related to managing critical incidents and employeepsychologicalwellbeing.WhenFLMsarenotequippedwithsufficientskillstosupporttheiremployeesoridentifywhentheyaresufferingfrom mental health difficulties, this places additional pressure onotherinformalsupportpersonsandtheformalsystemofsupport.Thefollowingquotesillustratestheseviews:

Iwentthroughastagewherewehadalotofveryaggressivepatientswhowerejustincrediblyabusive.WhenImentionedthattomy[FLM],herresponsesimplywas,‘well itmustbeyou, you're the only one having these problems’ - and shewalked away. There was nothing about, ‘okay what'shappening-whyisthishappening- let'shavea lookat it -let's sort of work through if there are better ways ofapproaching this’. None of that. Then what I foundsubsequent to our conversation was that most of mycolleagues were having similar issues with theirpatients. They justweren't tellingherabout it. Theyweretalkingaboutitamongthemselves[Interview21].

“There'snotrustthatyouwillgetunderstanding,compassion,supportor

confidentiality.Noneofthoseisguaranteed.”

“Noteverymanager,butdefinitelysomemanagers,will

turnonyouiftheyknowyouare

havingtrouble.”

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Wehavethisrelianceonmanagerstoidentifyproblems.Whenyou'vegotPTSDorany other stress indicators you are inherently trying to discredit the symptomsyourself.Youmaskthemandyouactivelygotohidethem.Whenyourmanagerhasbeeninthejobalmost40yearsandsometimesI’mtryingtosee-ifeveryone'sgotshitcolouredglassesonandyou'realltryingtolookthroughthesamelens…Whathappensisweallgetintothisrutof-youtellmeifyou'vegotproblemsandthenI'llseeifIcanidentifyandI'lltellyou.It'sasystemthat'sdoomedforfailurebecause(1)theemployeestriestohideitand(2)theemployergenerallyyourmanager,isthattaintedaswellbythejob.They'vegotprobablyanunderlyingdegreeofPTSDandtheycan'tseeitinthemselveseither[Interview29].

2.3 EMPLOYEEVOICEEmployeevoice(theactofspeakinguptoseekimprovements)cancomethrougharangeofavenues,formalandcollective,forinstance,throughaunion,orinformalandindividualwithanemployeeraisingamatterofconcernwithamanager.Thereisanextensivebodyofresearchdemonstratingtheimportanceofemployeevoicetotheorganisation(forexample,businessimprovements,errorreporting)andtheemployee(suchasemployeewellbeing,fairtreatmentatwork)(seediscussionseeWilkinson,Dundon,Donaghey,&Freeman,2014).

Interviewed staff in all three jurisdictions stated the preference for the union to play a role as a‘backstop.’Bythis,staffmeanttheywantedtobeabletocallupontheunion,butdidn’trequiretheuniontobeinvolvedinallissuesasstaffmightwishtospeakuporinteractwiththeirmanagersinsomecircumstances. Thus theunion from the staff view shouldnot takeon the rolemanagement is (orshould)beperforming.Forexample:

InsomewaysIkindofthinkthatwe'reemployedtodothisjobsoouremployershouldbetakingresponsibilitytomakesurethatourwelfareislookedafter.Ithinkiftheuniondoestoomuchtohelptheninsomewaysouremployersortofsays‘ohwedon'thavetoworrysomuchaboutthatbecausetheunionwilllookafterthat’.SoI'dliketoseefirstthatouremployerisdoingeverythingthattheyshouldbe,notjusttosay…‘wecan'taffordthatsowejustcan'tputitin’.Notheyshouldbeprovidingservices,betterservices,moreaccessible-theyshouldbetryingalothardertodothatandIdon'tthinkthattheunionshouldbepickinguptheslack[Interview38].

Thisbackstoprolefortheunionwasseenasveryimportanttotheoveralleffectivenessofthesupportnetwork:

Ithinkonething(theunion)havedoneistouchbasewithus…actuallyinitiatedsomeproperbackgroundinformationtoworkoutexactlywhatisneeded.Idon'tbelieve

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foronesecondthatwewouldhaveactuallygotthisfromourmanagementstructure…toactuallylookat,explorewhatthepotentialissuesareandlookatstrategieswhichcanbeputintoplacetominimiseproblems.Iverymuchseethemanagementtoofocused on productivity and performance indicators.Quite frankly there's a lot ofpeoplelinedupforthejobsoifweareoutforpsychologicalorotherreasons,that'sallright,theycangetanotheronein[Interview47].

Inferred from this is that unions play an important and valuable role but this is carried out on anepisodicbasisastheunionsdonothavethecapacityfordailyongoingimpactontheground.Togivestaff the capacity to voiceon theground requires voice systemsandmanagement support. This iswidelyrecognisedbyallthestakeholderswithinthisresearch.Managementtherefore,needtoensureclear and well-functioning systems with clear pathways to raise (and escalate matters), and thatemployeeshavetrustinthesystems.Thiswillfacilitateemployeevoice,withtheunionasabackstoptoensureallmajorissuesareidentifiedsomewherewithinthesystem,beitbymanagers,employeesortheunion.

2.4 WORKPRESSURESEmergencyservicesorganisationsandtheunionssupportingemployeesareacutelyawareparamedicsandassociatedambulancepersonnelneedsupporttohelpthemcopewithexposuretotraumaticevents.ThisiswhyEmployeeAssistancePrograms(EAPs) and formal support mechanisms are almost universally provided in theseorganisations. Our study identified, while mechanisms were in place, there areindividualandorganisationalfactorsthatimpedeemployees’willingness,capacityoropportunitytoaccessEAPmechanisms,forexample,workload,thetimingofcontact,andindividualrelationships.

Findingsalsoshowaccesstoinformalsupport,suchasthatofferedviapeer-to-peervoice,hasbeenrestricted due to work organisation changes. Changes to work organisation in many cases, andshortagesofskilledpersonnelatothertimes,hasledtoincreasingdemandsandtheorganisationalandoperationalstressorsfortheparamedics.Thisrequires longerworkinghours,fewerbreaksandlesstimespentatthestation,alongwiththerequirementtoundertakemoreoperationaltasks,suchasthecompletionofpaperwork.

Furthermore, findings reveal consequences of changes in work organisation, such as reducedopportunity for ‘down time’ with their peers in the ambulance vehicle or at the station and thatparamedicswerelesslikelythanpreviouslytoengageinpeer-to-peervoiceinordertodebriefafter

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theirexposuretotraumaticevents.Therefore,notonlyhad their organisational and operational stressorsincreased,whichwouldincreasetheirriskofdiminishedpsychologicalwell-beingandPTSD,butamajorsourceofsupport for officers to cope with those stressors (i.e.peer-to-peervoice),hadbeenlimited.

Our findingsdemonstratechanges inworkorganisationmayimpactparamedics’capacitytoconserveresources,duetodiminishedopportunitiestobuildsocialcapitalasaresourcethatcouldbeaccessedonaregularandad-hocbasis. This has important implications for the employing organisations and the role they play indesigningworkorganisation.Thus,itisimportanttobecognizantofensuringHRMsupportpracticesareadopted that can increaseemployee resources todealwith theorganisationalandoperationalstressors,alongwiththetraumaticexposure,towhichparamedicsareexposed.Equally,itisimportanttohavemechanismsinplacetoidentifyandrespondtotheimplicationsofworkorganisationchangesandtoensurethatopportunitiesforinformalpeer-to-peervoiceareconsidered.

Changestoworkorganisationinmanycases,andshortagesofskilledpersonnelatothertimes…requireslongerworkinghours,fewerbreaksandlesstimespentatthestation

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SECTION 3 ADDITIONAL CONSIDERATIONS

3.1 HIGHRELIABILITYMANAGEMENTThereisgrowingresearchandpractitionerinterestin‘reliabilityseekingorganisations’(RSOs). Essentially, RSOs are focussed on reliability, safety and resilience overproductivity,profitsandperformance,andthereforearestructuredandoperateinawaythatcontrastswithmostotherorganisationaltypes.AccordingtoWeick,Sutcliffe,andObstfeld(1999),RSOsareunique inthattheyare:committedtodetectingandunderstandingfailures;sensitiveandmindfultohazards;comfortablewithcomplexityand reluctant to simplify; resilient and able to respond and adapt to crises; andflexible,withahierarchythatallowsdeferencetosubjectexperts.

OrganisationsareincreasinglyidentifyingasRSOsacrossbroaderindustries,andinparticular,inhealthcareandemergencyservices.Inemergencyservicesorganisations,safe,consistentandreliablecareofpatientsistheprimaryobjective.Hence,identificationwiththeRSOapproachisbeneficialasitenablesthe organisation to consider whether its systems, processes, culture and philosophy are suitablyaligned.ThewaypeoplearemanagedinanRSOcontrastswithageneralhighperformanceapproachtoHRM,andtherearesomepracticeareasthatshouldbeconsideredifanorganisationisfocussedfirstonsafetyandreliabilitybeforehighperformanceobjectives.

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Forexample,inRSOs,agencyandcontractworkers-whoareunfamiliarwiththeorganisationsvaluesandsystems–cancompromisereliabilityandaregenerallyunsuitable.PerformancemanagementinRSOspermitszerotoleranceofattitudesandbehavioursthatareinconsistentwiththeRSOphilosophy.Learninganddevelopmentactivitiesaresophisticated,well-resourcedandfocussedontechnicalskills,mindfulness, and responding to emergency situations. Financial incentives in RSOs can motivateemployees to prioritise performance targets over safety and reliability and are therefore generallyunsuitable.RSOsrequirestrictaccountabilityprocessestosupporterroridentification,andhierarchiesthat allow flexibility in emergencies. Additionally, there is a requirement for over-staffing andduplicationinRSOs,toensurereliabilitycanbemaintainedincrisiscircumstances.

Trainingprogramscurrentlyinplacearesubjecttoanumberofissuesthatcompromisethereliabilityofoutcomes.Theseincludegeographicalrestraints(i.e.remoteanddistantstations),accessibilitytoonline

content,andlackofsophisticatedandtechnologicallyadvancedtrainingdeliveryresources.

TherearesomeaspectsofthisRSOapproachtomanagingpeoplethatmaybeofparticularinteresttotheAustraliancasesinvolvedinthisresearchproject.Thereisfeedbackindicatingtrainingprogramscurrentlyinplacearesubjecttoanumberofissuesthatcompromisethereliabilityofoutcomes.Theseincludegeographicalrestraints(i.e.remoteanddistantstations),accessibilitytoonlinecontent,andlackofsophisticatedandtechnologicallyadvancedtrainingdeliveryresources.Anotherinconsistencyidentifiedisthelackofduplicationorover-staffingofcriticalroles.ThiscoreissueisatoddswiththeRSOapproachasitdoesnotallowforflexibilityandconsistentresponse,andalsoleadstostaffburnoutand compromised reliable performance. Further investigation into the applicability of the high-reliability philosophy would be beneficial to achieve better alignment between the goals of theorganisationandthemanagementofemployeesandrelatedsystems.

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3.2TRAININGFORIMPROVEDRESILIENCEAkeyfindingfromtheinterviewsacrossthejurisdictionswasthatthereisvariationintheapproachestobuildingresilience,andthatsomestateshavestrongerprogramsthanothers.Thisoffersanopportunitytolearnanddevelop,withfeedbackprovidedonspecificapproachestoincreasingtheresilienceoftheworkforce.

First,asnotedinSection2.2.1Formalsystemsofsupport,thereisverylimitedconsiderationgiventopre-employmentpreparation forcandidate’smentalhealthandresilience.Given the intakeofnewgraduatesisgenerallyveryyoung,thisplacesagreatdealofresponsibilityontheemployingentity.Itmaybepreferableforthetertiaryinstitutiontobeginpreparinggraduatesmentallybeforetheyareplacedintheirfirstpositionandexposedtotraumaandthestressoftheparamedicrole.Formationofacommittee,includingrepresentativesofemployersandunions,couldbegintoaddressthisdeficiencyand make recommendations for pre-employment resilience training and discussion. As anorganisationalpsychologistsuggested:

Itwouldbegreattosee,inauniversitysomewhereinAustralia...Wheretheydoanintroduction to managing clinical stress in the workplace. Second year they'reintroduced into research methods and mental health and understanding mentalhealth.Yearthreeiswheretheylookattheactualpractical,wherethere'snoexam,butit'ssimplyalecture,everysemestertwoorwhatever,wherethey'reactuallybeingtaughtthetechniquesofde-escalation[Interview60].

Furthertothispoint,datasuggeststhatparticipantsareseekingextendedresiliencetrainingprogramsparticularlyinSouthAustraliaandNorthernTerritory.Whilethisisexploredinsection2.2,wereiterateherethatparticipantsindicatedtheywouldgainvaluefromongoingtraininginthisarea.Furthermore,intervieweesnoted training for supportpersons (peers, familyand friends)wouldbebeneficial forthem.Finally,thetrainingforFLMsandteamleadersadoptedbytheQueenslandserviceisapositivesteptoaddressingtheissuesnotedinSection2.2.4(Frontlinemanagers).Thisprogramisworthyofconsideration by other services not currently trainingmanagers in how to improve their ability toidentify mental health issues, manage affected staff members, and facilitate a supportive workenvironment.

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3.3 MEALBREAKSANDRETURNTOBASEPROVISIONS

There are differences between states in the provisions that require employees toreturntothestationfortheirmealbreakduringtheshift.Therequirementtoreturntobaseisimportantasitmaybeassociatedwithfatigue,burnout,andcouldinfluencethementalhealthofemployees.Returning tobasehasmultipleperceivedpositiveoutcomesthatappeartoaffectemployeesstress,anxietyandenergylevels.InSouthAustraliaandtheNorthernTerritory,theprovisionforparamedicstoreturntobasebetween jobs for a meal break has been met with a positive response fromparamedics.

You’regoingbacktoafamiliarplace.You'regoingbacktoyourarea.You'regoingbacktoyourstuff,yourfood'sinthefridge.It'smorerelaxing.Iftheywouldsendustoastationthatyoudon'tknowwithacrewthatyoudon'tknow,it'slikegoingintosomeoneelse'shouse.It'snotascomfortable[Interview35].

Asthisquoteexplains,thereturntobaseprovisionishighlyvaluedasemployeescanrelaxinafamiliarenvironment,allowingthemtodefuseanddestressduringashift.Thereistheadditionofenablingemployees to eat a pre-prepared (and likely healthier)meal among colleagues, in amore civilisedmanner,comparedwiththesituationin“someoftheotherstates,theirmealbreak-theyhaveitonthesideoftheroad”[Interview27].Or,asanotherintervieweeputit,“inotherstates,don’teventhinkaboutgettingamealbreak,youbettertakeitintheambulanceandeatitwhenyoucan!”[Interview25].

Despitethisprovision,itstillappearstobecommonforparamedics,particularlyinmetropolitanSouthAustralia and Queensland stations to be experiencing such high workloads that meal breaks arerestricted,delayedbyseveralhours,ornotoccurringatall.

We’vehadsomanycases–ithappenseverydaywherecarsarehoursandhourslatefortheircrib[break],orhourspastknockoff,butthere’snooneelsetosendtothejob…We’vehadsomecrewsthathavegoneeight,nine,10hoursbeforetheygettheirfirstbreak.Ireckonwe’vehadcarsthathavedoneafull12-hourshiftwithouthavinganycribbreak[Interview30].

Restrictionstomealbreaksofemergencyservicesworkersmightbeseenasunavoidableinthecurrentclimateof budgetary restrictions and lean staffing arrangements.While theprovisions inNorthernTerritoryaresimilartoSouthAustralia,therearegreaterfinancialpenalties.Ifparamedicscannottakeameal break after four hours, they receive pay at double-time until they are able to break. Oneparticipantexplainshowthischangewasperceived:

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We'requiteluckyhere.Ourunionwasbrilliantone-year,negotiatedmealbreaks.Whentheyfirststarted,itwasall a bit all over the shop. They would just send youanywhere.Now,theygetyoubacktoyourhomecentreandyouwillhaveyourmealbreakthere.Itisbrilliant…Youhavetogoback-ifyou'vegotahotmeal,youcangobacktowhereyourbagis. Youcansitdownthere.Thatisyourhomestation[Interview25].

Theintervieweegoesontosuggestthehomebaseprovidesan‘anchor’ to take a moment out from what might be a hectic day, in a secure and comfortableenvironment. The higher financial penalty is an attempt to lessen the employee dissatisfactionassociatedwithdelayedandmissedmealbreaks.Althoughtheadditionalcompensationiswelcome,itdoesnotaddressthefundamentalmatteroftheassociatedphysiologicaleffectsofdelayedmealsandrestinanintenseandoftentraumaticrole.Asoursurveyfinds,highfatigueisproblematicforoverhalfofstaffineachjurisdiction.Thereturntobaseprovisionisessentiallyausefultooltoaddressfatigue.However,thereareconcernsparticularlyintheNorthernTerritorythattheprovisionwillnotremain.

Fatigue'sabig(issue)…iftheydon'tgetabreak(intheNorthernTerritory),theygointoovertime.StJohnhavebeentryingtogetridofthatforaverylongtimeand…weknowthey'retryingforitagain.Theytryforiteverytime,butitjustdoesn'tgetup.Becauseourmembersdon'ttrustforthemtoprovidethebreak.That'swhytheyhavethispenalty.That'swhywebroughtitin.Becausetheyactuallyhad-weregiventwoyearsontheagreementbeforeitkickedin,toaddressfatigueandtheyneverdid.Sonowit'scostingthemalotofmoney.Buttheydon'taddressfatigue.Theytriedtoremovetherestandreclineclauseintheiragreement[Interview18].

This excerpt is important as it indicates that staff acknowledge theprovision is to address fatigue,howevertheyoftenstillhaveissuesreturningtobaseinareasonabletime.Hence,theybelievethefinancialpenaltiesareatleastacompensationforthefatiguetheyexperienceonaregularbasis,andwishtoretainitastheydonotfeeltheirfatigueissuesarealwaysaddressed.ThescenarioissimilarinQueensland,wherework intensification continues toaffectmealbreaksand finish times, althoughthereisnotprovisionforreturntobaseorassociatedfinancialpenalties.Acrosstheboard,itisafairlypervasiveviewthat,“ifyoujointhejobnowexpectingtohaveamealonshiftorexpectingtofinishontime,you'reinthewrongcareer”[Interview5].

“Ifyoujointhejobnowexpectingtohaveamealonshiftorexpectingtofinishontime,you'reinthewrongcareer”

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3.4 CHANGESTOWORKFORCEPROFILEThere are significant changes affecting the workforce profile of the paramedicprofession.NewlyqualifiedapplicantsareprimarilyveryyoungandoverhalfinSouthAustraliaandQueenslandarefemale.Therearesomeeffectsofthesechangesthataregoingtobeexperiencedbytheserviceonanationalleveloverthecomingyears.

Asyoungapplicantsbegintostartfamilies,thealreadystrongdesireforflexibilityisgoingtoincrease.FlexibleworkarrangementshaveseensomeimprovementwithintheSouthAustraliaandQueenslandservicesoverthedurationofthestudybutaccordingtointervieweesthereismuchscopeforfurtherdevelopment:

[There]isanever-increasingwishforflexibleworkarrangements.Don'tquotemeonthenumbersbutwhenwedidourWorkingforQueenslandsurveylastyearoneofthequestionswasaroundflexibilityintheworkforce,andthestatthatinterestedmethemostwastherewasonequestionaroundifyouwantflexibleworkoptionsandyouhaven'tgot itwhy. Theoverwhelmingnumber in the70oddper centwas that, IthoughtifIaskedforitIwouldn'tbegivenit.Becauseatthemomentthereisverymuchalargelypermanentfull-timeworkforcesopeoplearethinkingIwonderifIcangethalf-timeoreitheraskingtheircolleagueorjustnotseeingitanywhereelseortheyjustthinkit'snotavailable…MoreandmorepeoplearestartingtosayactuallyIwouldn'tmind-ifwe'regoingtobebusyalldayI'dratherhaveashortershift,butagainthatpolarisestheworkforce.So,foreverypersonthatwantsaneighthourshiftthere'ssomeoneelsethatwantsfourdaysoffandthetwothingsdon'tgotogetherunlessyoulookatpart-timework[Interview64].

Another conversation that ties into these points raised above is increasing casualisation of theworkforce. An increased demand for casual work appears to be accompanying desire for greaterflexibilityasemployeestradesecurityformorecontroloftheirworkinghoursandrosters.Ashiftinthetypes ofwork arrangements also coincideswith employees taking time to bewith family throughparentalleave.

Sowehave-Ithinkit'sabout60percentofnewgraduatesarefemale.Sonotallofthemaregoingtogetmarriedandhavekidsbutthere'sagoodchancethatalotofthemwill.Soweneedtobepreparedforthatshiftinourworkforce.Thecasualisation-andnotjustthefeminisationbutthecasualisation-wherepeopledojustwanttohaveadifferentlifestyleandhaveflexiblearrangements[Interview68].

Asthis intervieweenoted,theincreasingproportionoffemalerecruitscombinedwiththechangingconceptualisationofjobsecurityandworklifebalancemeanstheservicewillneedtofocusontheirresponsetomanagingtheworkforce.ThereispressureontheHRMdepartmenttoensurepoliciesandstrategy continue to focuson the changingenvironmentand labour forcedemographics toensureconcurrentchangingneedsareaddressed.

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3.5 FUTUREAVENUESOFEMPLOYMENTFORPARAMEDICS

A topicof conversationwhichour interviewees felt strongly aboutwas the lackofcareer progression or development opportunities for paramedics. Outside ofincreasedclinicalskilldevelopmentandmanagerialpositions,intervieweesexpressedconcern that there was great difficulty in moving into other related positions orprofessionswithoutcompleteretraining.

Thereareanumberofstrategiesbeingadoptedbyindividualsandorganisations,forexample,someparamedicsareworkinginpart-timeorcasualroleswhiletheystudyinadifferentfield.Paramedicsmaystudyadualbachelor’sdegreewiththeintentionthatasecondcareerwillbeaccessiblewhentheyhavebecomeburnedoutfromthehighintensitylifestyle.Therearepathwaystopromotion,butasthefollowingintervieweenotes,therearefarmorepotentialcandidatesthanpositions.Giventhegrowingworkforceofintelligent,highlyqualifiedandmotivatedemployeescomingfromthetertiaryeducationsystem,thereareissueswiththestructureoftheparamediccareerandthelimitationsinfutureprogressionintomanagementorspecialisedroles.

Ithinkthatit'sveryhardwhenyou'vedonethisjobforalongtimetothinkorconsiderwhatelseyoucoulddothatcouldalsosustainthelifestylethatyou'velearnttolead,becausewe'rewellpaid.Ithinkyougetstuck.Whetheryouwanttobehereornot,youcan'tleave…Itbecomesveryhardtomove,there'slimitedoptionsforpeopletoget intomanagement roles.Wewould have a lotmore peoplewhoare suited tomanagementrolesthanwehavemanagementrolesforthem…ThepeoplewhodoleavemaybehavenursingdegreesbeforetheycametoSAAS,andmightgobacktonursing.Ormaybeaverysmalltoplayermightgooffanddomedicineorsomethinglike that. You hear occasionally of someone who might go and work in anotherambulance organisation because their family's had to move. Finally, maybesomeone'sgoneandworkedasamineparamedicorsomethinglikethat.Butnoneofthoseoptions,ifyouthinkaboutit,areoverlyenticingreally.Sotherearen'tawholelotofthingsforpeopletodoiftheydon'tbeaparamedic.Onceyou'rein,you'restuck[Interview53].

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3.6 PARAMEDICSANDTHECOMMUNICATIONSCENTRE

Therearearangeofstressorsintheparamedicrole,andoneoftheseisthetensionbetween paramedics and dispatchers in the communications rooms in eachjurisdiction.Thetensionsarenotalwayspresent,andappearmostattimesofhighactivity,forexample,whenthereisanacuteemergencyandtheaddressmaynotbeaccurate.Asoneparamedicexplains:

Most ambos that I've worked with and know believe that they can control theambulanceservicemuchbetterfromthefrontseatoftheirambulancethananyoneelse can…There'salways thatanimosity there, but it's become I thinkworse.Notreally worse, it's become different. Because of the detachment now, with thecivilianisationofthecommsroom.So,there'sstillafewolddogsinthere,butthey'refewandfarbetween.Sothesenewpeoplehavecome inascall takers fromsomeotherenvironment,sayfromataxiindustry,say.Noemergencyservices,noethosaroundthatreally,ornounderstandingIguessofthatoperationenvironment.Thentheyprogressthroughtobecomedispatchersandteamleaders,even,upthroughthechain, and it's become siloed evenmore so. By virtue of that civilianisation, it'sactuallybecomeworse,notbetter.Soyeah,itisaninterestingdynamic,thosetwothings[Interview44].

Interviews indicated stressors of the job are compounded when there is poor communication ormisunderstandings with dispatch staff. Organisational research points to improvements incommunicationandperformancewhenorganisationalsilosareremovedandindividualsunderstandtheperspectiveofotherswithintheorganisation(Phillips,2016).

Itmayalleviatethesetensionswith‘commsstaff’byimprovingunderstandingandempathybetweenboth groups of employees regarding the stressors and barriers involved in respective roles. Forinstance, having dispatch staffoccasionally attend jobs withparamedics, and equally, paramedicsspending some time in thecommunications centre. In fact,rotation of paramedics through thecommunication centre couldadditionallybebeneficial ifviewedasa short ‘career break’, addressingchronic stress, burnout, anxiety, andassociatedmentalhealthconditions.

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4 APPENDICES

4.1 APPENDIXA:SHIFTFROMDSM-IVTODSM-5

ThediagnosticcriteriaforPTSDweresubstantiallymodifiedfromtheDSM-IVtoDSM-5,whichinfluencedtheconceptualisationofPTSD.Thenewcriteriafortraumaandexposuretoitlimitthetypesofeventsthatqualifyastraumaforconsiderationofthisdisorderandchangequalifyingexposuretotrauma.ThechangeshaveclearlyhadanimpactonfindingsonPTSDinthepilotphaseofthisprojectandStudy1sotheyareworthyofconsideration.Asummaryofthemostrelevantchangesfortheambulanceenvironmentareasfollows.

In the new criteria, PTSD still requires exposure to a traumatic event but the definition usedwasmodifiedtorestrictitsinclusiveness.TheDSM-5definitionoftraumarequires“actualorthreateneddeath,seriousinjury,orsexualviolence”.Stressfuleventsnotinvolvinganimmediatethreattolifeorphysicalinjurysuchaspsychosocialstressorsarenolongerconsideredtraumainthisdefinition.

TheDSM-5hasalsonarrowedthetypesofeventsthatqualifyas“traumatic”.Thepreviouslyusedterm“threattophysicalintegrity”wasremovedfromthedefinitionoftraumaintheDSM-5.Medicallybasedtraumaisnowlimitedtosuddencatastrophesuchaswakingduringsurgeryoranaphylacticshock.Non-immediate,non-catastrophiclife-threateningillnessnolongerqualifiesastrauma,regardlessofhowstressfulorsevereitis.Thepreviouslyusedphrase“confrontedwith”,inreferencetoindirectexposurethroughcloseassociates,hasbeencompletelyremovedfromthedefinitionofexposuretotraumaintheDSM-5;thewitnessingoftraumatoothersnowhastobeinperson.

Medical incidents involvingnaturalcausesalsono longerqualify (withonesmallexceptionaboutaperson’sownchild).Thisrevisionofthedefinitionofmedicallybasedtraumainparticularhashada

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substantialinfluenceonPTSDfindings.Forexample,aDSM-IV/DSM-5comparisonstudyfoundthat60%ofPTSDcasesthatmetDSM-IVbutnotproposedDSM-5PTSDcriteriawouldbeexcludedfromtheDSM-5becausethetraumaticeventsinvolvedonlynonviolentdeaths(conductedbyKilpatricketal.,2013).

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4.2 APPENDIXB:FULLLISTOFINTERVIEWEES1Queensland,FrontlineManager 37SouthAustralia,CEO2Queensland,Paramedic 38SouthAustralia,Paramedic3Queensland,EmergencyDispatch 39SouthAustralia,Paramedic4Queensland,Paramedic 40SouthAustralia,Paramedic5Queensland,Paramedic 41SouthAustralia,Paramedic6Queensland,Paramedic 42SouthAustralia,Paramedic7Queensland,Paramedic 43SouthAustralia,Paramedic8Queensland,Paramedic 44SouthAustralia,Paramedic9SouthAustralia,Paramedic 45SouthAustralia,Paramedic10Queensland,Paramedic 46SouthAustralia,Paramedic11Queensland,ClinicalEducator 47SouthAustralia,Paramedic12Queensland,Paramedic 48SouthAustralia,Paramedics13Queensland,EmergencyDispatch 49Queensland,UnionRepresentative14Queensland,Paramedic 50Queensland,UnionRepresentative15Queensland,Paramedic 51Queensland,UnionRepresentative16Queensland,FrontlineManager 52Queensland,UnionLeader17Queensland,FrontlineManager 53SouthAustralia,FrontlineManager18NorthernTerritory,UnionLeader 54SouthAustralia,ManagerOperations19NorthernTerritory,Paramedic 55SouthAustralia,ManagerOperations20NorthernTerritory,Paramedic 56SouthAustralia,ManagerHR21NorthernTerritory,Paramedic 57SouthAustralia,ManagerOperations22NorthernTerritory,Paramedic 58SouthAustralia,UnionLeader23NorthernTerritory,Paramedic 59SouthAustralia,ManagerOperations24NorthernTerritory,Paramedic 60SouthAustralia,Org.Psychologist25NorthernTerritory,Paramedic 61SouthAustralia,Paramedic26NorthernTerritory,Mgr.Operations 62Queensland,ManagerClinicalEducation27NorthernTerritory,ManagerHR 63Queensland,ManagerClinicalEducation28SouthAustralia,Paramedics 64Queensland,DirectorOperations29SouthAustralia,Paramedic 65Queensland,DirectorEmployeeSupport30SouthAustralia,EmergencyDispatch 66Queensland,DirectorFinance31SouthAustralia,Paramedic 67Queensland,DirectorHumanResources32SouthAustralia,Paramedic 68Queensland,ManagerClinicalEducation33SouthAustralia,Paramedic 69Queensland,ManagerClinicalEducation34SouthAustralia,Paramedic 70Queensland,ExecutiveDirector35SouthAustralia,Paramedic 71Queensland,RegionalManager36SouthAustralia,Paramedic 72Queensland,Dir.Performance&Planning

*Note:Interviewnumbersabovecorrespondtonumberfollowingquoteswithinthisreport

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