Brighton Journal of Research in Health Sciences

Supporting Research in the School of Health Sciences


What causes inappropriate or avoidable use of urgent and emergency care services, and how far can the ambulance service reduce this through admission avoidance?


There are currently unprecedented levels of demand on urgent and emergency care throughout the UK (University of Sheffield Medical Care Research Unit 2010; Agarwal et al, 2011; NHS England 2013), with ED attendances and ambulance call outs increasing consistently every year (Nelson 2011; Newton et al, 2013). Accident and Emergency (A&E) departments are regularly missing the four-hour waiting target (NHS England 2013; BBC 2015) and there is national concern over the National Health Service’s (NHS) ability to cope with the increasing pressure (Press Association 2013; Cooper 2015).

With potentially 15% of the UK population utilising urgent and emergency care services at any one time, many accessing multiple services (Knowles, O’Cathain & Nicholl 2010), it is important to ensure appropriate use of frameworks in order to avoid any one service becoming over-burdened.Congested A&E departments have a direct and significant impact on ambulance service performance (National Audit Office 2011; NHS England 2013; Mundasad 2014), and whilst the link between ambulance and ED services should be fundamentally evident (National Audit Office 2011; Patton & Thakore 2012), often the two services are treated as isolated and even opposing entities. One example of this is the proposal of ‘forced handovers’ by ambulance crew in certain trusts (Johnston 2015; Local Ambulance Trust 2015).

The Bradley Report (Department of Health 2005) marked a fundamental recognition that ambulance services could not only reduce the amount of people admitted to A&E, but that this reduction could have a significant impact on emergency care and wider NHS services. The aim of this literature review was to establish how ambulance services can help reduce current demand on wider urgent care services and A&E departments in particular, through a greater awareness of inappropriate patient use, what causes it and how alternative care pathways can be utilised in order to reduce it. In doing so, this paper also aims to demonstrate the fundamental connection between ED and ambulance services, and how their performance is mutually dependant on one another.

Two semi-structured literature searches were conducted of CINAHL, PubMed, AMED, Cochrane Library databases and the Journal of Paramedic Practice; one exploring inappropriate use of services and one exploring prehospital admission avoidance. Twenty-seven articles were included for review and four broad themes were identified; Definition of Terms, Patient Factors, Access to Healthcare and Healthcare Frameworks.

A high number of diverse and complex contributors to inappropriate emergency department (ED) attendance and ambulance use were identified. Whilst some patient factors contributed towards this issue, problems with wider healthcare frameworks and organisational behaviours were significantly more abundant in reviewed literature. Fragmentation of services may be creating barriers to alternative care services to both patients and clinicians attempting to make referrals. Strategies to improve appropriate use of healthcare should focus on enhancing the way in which services work together.


A systematic search was performed using an adapted methodology from Moher et al (2009). CINAHL, PubMed and Cochrane Library databases were searched for key phrases in the title or abstract. A secondary search was conducted of the same databases using phrases including ‘Ambulance’, ‘Admission Avoidance’ and ‘Pathway’.
Additional keywords derived from iterative searches were added to search terms until appropriate saturation of results had been achieved. Boolean operators ‘AND’ and ‘OR’ were utilised to broaden and narrow results accordingly (Machi & McEvoy 2009).

Articles were critically analysed using a tabular matrix adapted from LoBiondo-Wood and Haber (2013). Key issues from each article where then extracted to create a thematic index (Thomas, Harden & Newman 2012).

Research conducted outside of the UK was excluded due to the internationally unique framework of the National Health Service. The exception to this was material considered in systematic reviews, where articles were included as long as they were written in the UK. Articles which focused solely on self-presentation at the ED, or which did not make any explicit differentiation between routes of attendance were also excluded. Articles published before 2010 was excluded due to changes in GP out-of-hours (OOH) services.

Material focusing upon paediatrics or specific medical complaints was excluded, with the exception of falls, and frequent users. All levels of evidence were included (National Institute for Health and Care Excellence 2006), with the exception of narrative expert opinion due to the limited quality of this evidence (GRADE Working Group 2004).

Definition of Terms

Of all reviewed material, only ten articles (Endacott et al, 2010; Agarwal et al, 2011; Jones 2011; May 2011; Patton and Thakore 2012; Booker, Simmonds and Purdy 2013; Newton et al, 2013; O’Cathain et al, 2013; O’Hara et al, 2014; Atenstaedt et al, 2014) explained how they classified inappropriate use, and of these, only a very few demonstrated significant effort to objectify definitions. Articles that did rigorously establish objectivity showed variation in their presented views. The University of Sheffield Medical Care Research Unit (2010) highlights significant inconsistency in defining appropriateness throughout healthcare research. Furthermore, Jones (2011) and Booker, Simmonds and Purdy (2013) argue that appropriateness is almost exclusively defined retrospectively by healthcare staff. This demonstrates the complexity of this particular area, and may explain conflicting views of appropriateness between ED and prehospital clinicians (Newton et al, 2011; Patton & Thakore 2012). However, whilst there exists significant challenges in objectively defining inappropriate use, clarification on what this looks like is crucial in aiding clinicians to identify and reduce it in real terms. Further research in this area would be beneficial in providing clearer guidelines for prehospital clinicians when dealing with potentially inappropriate use.

Patient Factors

A significant proportion of extracted themes related to subjective factors influencing individual patient behaviour. These could be categorised into four main sub-themes; Perception of Illness, Interpersonal Factors, Patient Demographics and Socioeconomic Factors.

Perception of Illness

Booker, Simmonds & Purdy (2013) found symptom and decision-making anxiety to be the superordinate theme of their research, often resulting in risk-averse decisions to summon the most immediate form of assistance. Whilst recognised methods were used to conduct thematic analysis, questionnaire content was derived from a previous pilot, rather than established evidence, resulting in potential content bias (Pannucci, & Wilkins 2010). However, this research was externally peer-reviewed, and several further articles provide consensus on this finding (Agarwal et al, 2011; University of Sheffield Medical Care Research Unit 2010; Edwards et al, 2014).

Conversely however, a literature review by Sheffield University (University of Sheffield Medical Care Research Unit 2010) highlights that misconceptions of symptoms can potentially cause inappropriate delay or refrain from contacting emergency services. Whilst the aforementioned makes no analysis of the ratio between inappropriate contact and non-contact, Kirkby and Roberts (2011) suggest that the majority of inappropriate classification occurs when no ambulance is required.

Patient education was highlighted as pivotal in several articles (Atenstaedt et al, 2014; Patton & Thakore 2012; Jones 2011; Kirkby & Roberts 2011). Atenstaedt et al (2014) demonstrates the effectiveness of targeted campaigns in improving patient knowledge and reducing inappropriate attendance, however provides no cost-analysis of these strategies. Perhaps a cost-effective opportunity exists for the ambulance service to deliver this type of patient education to inappropriate users. The ambulance service has previously demonstrated high levels of success in bringing health campaigns to public awareness (Association of Ambulance Chief Executives 2011). This is demonstrated by the recent stroke awareness campaign by the South East Coast Ambulance Service (South East Coast Ambulance Service 2015).

Interpersonal Factors

Similarly three articles considered interpersonal factors such as relatives and carers in the decision-making process. Booker, Simmonds & Purdy (2013) found interpersonal factors often reduced tolerance for medical risk. They found that informal carers often experienced feelings of responsibility and helplessness, prompting them to take the least risky course of action. In addition, risk-minimising behaviour was noted in patients themselves, who often felt pressured by what friends and family might think, regardless of their actual presence. Whilst a single site limits this research’s external validity (Steckler & McLeroy 2007), verbatim transcripts noted this as a reoccurring theme in interviews. The Association of Ambulance Chief Executives (2011) outlines similar risk-averse behaviour from staff in care homes, however primarily driven by misconceptions of organisational responsibility.

The Keogh Review (NHS England 2013) suggests that self-care is a crucial influencer of service demand. In many cases this is dependant on patient and carer confidence managing minor ailments and long-term conditions.

Interpersonal factors can significantly influence subsequent use of ambulance services, and therefore should be considered by the prehospital clinician when attending an incident. It is also important for clinicians to recognise how interpersonal factors and support networks can influence a patient’s ability to self-manage, as this is pivotal information when making referral or non-conveyance decisions. In addition, clinicians should be aware interpersonal pressures when assessing patient wishes and when making best interest decisions.

Patient Demographics

The Keogh Review (NHS England 2013) identifies that the patient demographics most likely to benefit from alternative healthcare support are those least likely to be aware of it, prompting increased inappropriate dependence on urgent services. Several articles studied the effect of patient demographics on healthcare usage. Whilst Kirby and Roberts (2011) found no statistically significant factors in their research, Dent, Hunt and Webster (2010) found that frequent ED attenders were more likely to be male, with a mean age of 49. In a systematic review, Scott et al (2013) finds several concurring articles identifying frequent users as predominantly male. Despite some potential bias introduced from a single initial reviewer, established methodology and quality analysis is employed.
Edwards et al (2014) and Smith and McNally (2014) both agree that elderly demographics can make up a significant portion of inappropriate and frequent users. However, Scott et al (2013) found highly mixed evidence in regards to patient age, and only one limited study suggesting that frequent use increased with age.

Reviewed literature demonstrates mixed evidence in relation to patient demographics, and caution should be taken by the prehospital clinician in stereotyping frequent or inappropriate users of healthcare (Donohoe & Blaber 2008). The majority of evidence suggests that inappropriate users are heterogeneous, presenting for a variety of health and social reasons (Edwards et al, 2014; Scott et al, 2013).

Socioeconomic Factors

In a quantitative ecological study, O’Cathain et al (2013) found that areas of social deprivation, and urban areas had significantly higher numbers of avoidable emergency admissions. Whilst many confounding variables were not considered in this research, including distance to hospital, these factors were statistically calculated as significant, with a combined predictor of 75% in admission avoidance variation. In addition, many articles support this finding (Agarwal et al, 2011; Association of Ambulance Chief Executives 2011; Scott et al, 2013; Edwards et al, 2014; Smith & McNally 2014).

Conversely to O’Cathain, O’Hara et al (2015) suggested through qualitative research that rural areas had limited access to alternative pathways, and were more likely to see increased inappropriate ambulance transport. However, this research was limited by a small sample size at risk of self-selected participant bias (Lavrakas 2008). This furthermore contradicts evidence from the National Audit Office (2011) highlighting increased ‘see and treat’ rates in rural areas.

Whilst there exists conflicting views regarding geographical influence on appropriate healthcare use, there is an overwhelming consensus of evidence suggesting social deprivation contributes towards inappropriate and frequent use of urgent services. Healthcare campaigns have demonstrated success when socioeconomically targeted (Atenstaedt et al, 2014), and strategies by ambulance services to manage inappropriate use appear well advised to be initially targeted at economically deprived areas.

Access to Community Care Services

Several articles discuss patient access to community services as an influencing factor of avoidable ED attendance and inappropriate ambulance use. The Keogh Review (NHS England 2013) highlights significant variation in GP service satisfaction levels nationally, with systemic fragmentation of community services causing further access issues. This is supported by Agarwal et al (2011), which found GP access issues to be a consistently reoccurring theme in patients attending the ED inappropriately. In similar semi-structured interviews, Booker, Simmonds and Purdy (2013) also found that previous experience accessing community services and perceived limitation of GP capabilities heavily influenced patients’ decision to access ambulance services with primary care issues. This might explain why in highly rigorous, mixed-method action research, Endacott et al (2010) found that inappropriate ED attendances increased dramatically during OOH periods. If barriers to community care increase rates of inappropriate ambulance and ED usage, this has significant implications for ambulance services in analysing patterns of demand and managing response levels geographically and at different time periods (NHS Office of Strategic Health Authorities 2008). Evidence also suggests ‘post code’ variation in access to GP services (Raleigh & Frosini 2012; NHS England 2013), and further research into this area is warranted.

O’Cathain et al (2013) found that patients’ perception of good access to GP services was initially linked to lower ED attendance rates at primary stages of analysis, however when considering further variables such as overall ED and ambulance demand, actually contributed to higher attendance rates through GP referral. Indeed, Turner et al (2013) outlines the potential for supplier-induced demand, particularly in the area of alternative community services such as NHS 111. The Keogh Review (NHS England 2013) supports this notion, and furthermore highlights that GP consultations have also been increasing, despite expansion of alternative services. Therefore the issue may be more related to general demand rather than patient access. This is supported by Edwards et al (2014), which found that frequent use of emergency services was linked to equivalent frequent use of other community services.

However, as Patton and Thakore (2012) found GP referrals via the ED were associated with lower levels of inappropriateness, it is still reasonable to suggest that better access to GP services could improve avoidable ED admission rates. This is supported by Jones (2011), which, despite limitations in external validity (Steckler & McLeroy 2007), saw on-site GPs contribute to a reduction in avoidable admissions and improved waiting times at one district hospital ED. Paramedic Practitioners are now working more closely in supporting community GP services (Association of Ambulance Chief Executives 2011), and therefore perhaps this should be an important focus by ambulance trusts in managing overall demand.

Convenience of Emergency Services

Inversely, ease of access to ambulance and emergency department services was also a reoccurring contributor to inappropriate use of these channels. Patton and Thakore (2012) surmise that the convenience of an ED providing 24-hour investigations without appointment must significantly influence patient behaviour, however this was not explicitly analysed in their research. Smith and McNally (2014) propose a similar rationale for frequent users of urgent and emergency care services, and furthermore speculate a similarity in the behaviour of ED and ambulance users; a view supported by Edwards et al (2014). The notion of access simplicity is also supported by Knowles, O’Cathain and Nicholl (2010), who found that multiple referral pathways were linked with lower levels of satisfaction in the majority of patients. Through random quota telephone surveys, this paper also found high levels of satisfaction with Ambulance and ED services in particular, despite low levels of satisfaction with GP OOH and NHS Direct services. Indeed, the Keogh Review confirms that patient experience of ‘999’ emergency services is consistently positive; “overwhelmingly” so for patients with non-urgent conditions (NHS England 2013, 26).

Agarwal et al (2011) found confusion over alternative pathways to be a main contributor to patients accessing urgent services inappropriately. Participants in this research cited familiarity of services, and perception of efficiency over GP services as important influencers on the decision to attend the ED. Similarly, Booker, Simmonds & Purdy (2013) found users quoted previous positive experience and convenience of access to be primary contributors in their decision to access urgent care.

All articles appeared to demonstrate generally high levels of satisfaction amongst patients utilising ambulance and ED services, putting these services in the predicament of generating increased demand through positive performance. This represents a significant dilemma for the NHS, as these channels are by far the most expensive routes for patients to access health services (NHS England 2013). In addition, recent declining patient satisfaction levels for ED services demonstrate the consequences of demand surpassing a service’s capacity (NHS England 2013).

However, if adequately resourced, this could be viewed as an opportunity for the NHS to give more robust signposting and referral powers to a service with which patients are already confident using (National Audit Office 2011; Booker, Simmonds & Purdy 2013; Smith & McNally 2014). Patton and Thakore (2012) find that ambulance admission avoidance could reduce demand on ED services by 11%; a view supported by established literature (Department of Health 2005; The Association of Ambulance Chief Executives 2011). In addition to improving the overall profile of the ambulance service within the NHS, the National Audit Office (2011) estimates that this would be a significantly more cost-effective response model if configured appropriately.

Healthcare Frameworks

The Francis enquiry (2013) demonstrates how an organisational culture, and clinical behaviours within that culture, can have a significant impact on the quality of healthcare delivered to patients. A large majority of articles considered organisational and clinician factors in relation to inappropriate and frequent use of emergency care. Extracted themes could be broadly categorised into four subheadings; Triage and Clinical Decision-Making, Multidisciplinary Collaboration, Specialised Roles and Service Management.

Triage and Clinical Decision-Making

Sensitive triage and risk-averse behaviour are an integral part of NHS culture (NHS England 2015), and whilst risk management is an important consideration for any healthcare system (Turner et al, 2013; O’Hara et al, 2014), it can also contribute towards inappropriate use of emergency channels.
Patton and Thakore (2012) demonstrate the potential impact of oversensitive triage from ambulance staff. They found that a third of ED attendances were transported via ambulance, and of these admissions, 30% were deemed inappropriate. Whilst a potential bias exists with the duty consultant subjectively assessing appropriateness, reviewers did rotate throughout the study, and rigorous assessment was made using both the ED notes and Patient Report Form (PRF). Further articles support the suggestion of inappropriate ED referral through risk-averse or unsuitable ambulance triage (Newton et al, 2013; University of Sheffield Medical Care Research Unit 2010; O’Hara et al, 2014). However, Newton et al (2013) and O’Hara et al (2014) highlight the complexity of prehospital decision-making, particularly with low-acuity incidents.

A recent qualitative exploration of current treat and refer guidelines (Colver, Abhyankar & Niven 2015) highlights variation in prehospital use, and suggests further education and support for clinicians. In addition, Newton et al (2013) demonstrates the moderate success of prehospital pathway finders adapted from the Manchester Triage System. However, whilst providing clinicians with support tools may improve confidence, it may be argued that such tools do not address the issue of clinician education, and furthermore may be inappropriate for clinically and socially complex situations.

Oversensitive triage was also outlined as a primary contributor to increased ambulance workload by telephone services such as NHS ‘111’ (Turner et al, 2013). The issue of over-triage through telecommunications is furthermore supported in several articles (University of Sheffield Medical Care Research Unit 2010; Knowles, O’Cathain & Nicholl 2010; NHS England 2013). In this respect, the potential of a ‘snowballing’ effect of systemic over-triage through multiple services can be observed (Department of Health and Ageing 2007).

A proposed solution to this may be the implementation of secondary triage systems (Eastwood et al, 2014) in order to decrease sensitivity whilst maintaining risk management. However there exists little evidence on the most appropriate structure or benefits of this within a prehospital framework, and further research is warranted.

Multidisciplinary Collaboration

As previously discussed there are some perceived and tangible patient access issues to community care services (Booker, Simmonds & Purdy 2013), and this is also reflected in prehospital referral pathways (O’Hara et al, 2014).

The National Audit Office (2011) highlights the importance of multi-service collaboration in reducing overall demand, and the knock on effect when one service becomes congested. This is supported by further articles (Booker, Simmonds & Purdy 2013; NHS England 2013), which suggest that fragmentation of services is a heavy contributor to inappropriate use. Indeed Edwards et al (2014) and Smith and McNally (2014) both concur that collaborative multi-level interventions are most effective in tackling frequent and inappropriate use, whilst Booker, Simmonds and Purdy (2013) call for closer collaboration between primary care and ambulance services.

In a mixed-method qualitative study, O’Hara et al (2014) identifies the lack of available care alternatives as a key contributor to inappropriate ED attendance via ambulance. Whilst this was a relatively small study, this theme reoccurred consistently throughout three individual trusts, suggesting a high level of reliability (May 2011). However, the National Audit Office (2011) highlights a paucity of ambulance trusts adequately collating directories of alternative services, suggesting that the underlying issue may be prehospital awareness, rather than availability.

Specialised Roles

In a literature review by Coates (2013), Emergency Care Practitioners (ECP) were found to significantly reduce the number of patients conveyed to hospital, with estimates of approximately £20k in annual ED cost reduction per ECP. This is furthermore supported by Mason et al (2010), which found that ECPs increased admission avoidance rates, and were most effective in a mobile setting.
However Coates (2013) rightly questions the difference between avoided admission and avoided ED attendance, highlighting a paucity of studies differentiating between the two. Since a significant cost difference is applicable, further research in this area should be considered.

Reviewed material demonstrates that specialised roles have a significant benefit on admission avoidance, concurring with established literature (National Audit Office 2011; Association of Ambulance Chief Executives 2011). However, there is still variability in the deployment of these roles (NHS England 2013), and whilst there remains such a heavy prehospital focus on targeted response times over clinical outcomes (National Audit Office 2011), it may be argued that specialised prehospital roles cannot be utilised to their fullest potential.

Service Management

O’Hara et al (2014) highlighted several organisational factors which influenced clinical decisions to transport patients to the ED when alternative care may have been more appropriate. These included availability of diagnostic equipment, availability of remote support and appropriate initial staff deployment. Clinicians also felt that lack of vehicles and resources increased the pressure to reduce on-scene times, prompting them to avoid time-consuming referral pathways. Endacott et al (2010) also identifies inconsistencies in ED management of inappropriate attenders. Despite having debatable direct impact on ambulance services, this demonstrates the difficulty of managing inappropriate use in a controlled environment, and suggests greater management complexities in the prehospital setting. Indeed, Edwards et al (2014) outlines the challenges of individual case management for frequent users.

In addition, the University of Sheffield Medical Care Research Unit (2010) outlines the difficulty of service management across boundaries, and how tensions between local and national policies can negatively affect management proficiency. This tension is reflected by the National Audit Office (2011), which highlights additional variation between trusts in resource deployment and performance measurement, and limited sharing of best practice.

The Keogh Review (NHS England 2013) demonstrates how variation in service management can lead to patient confusion, significantly reducing appropriate help-seeking behaviour. It is apparent that national standardisation of service management across ambulance trusts may improve how patients access urgent services. In addition, improving training and resource support for responding clinicians may also significantly increase use of referral pathways.


An unexpected finding of this review was the distinct lack of clear definitions outlining what constitutes avoidable attendance and inappropriate use of services. A significant number of articles did not establish how appropriateness was measured, and those that did relied almost exclusively on retrospective opinion. Few articles subsequently highlighted rationales for concluding that patient behaviour was inappropriate, and those that did mostly presented their rationales narratively through interview extracts (Agarwal et al, 2011; Booker, Simmonds and Purdy 2013).

Booker, Simmonds and Purdy (2013) argue that appropriateness is almost always defined retrospectively by the healthcare professional, which would certainly explain why such a paucity of objective definitions exists. Furthermore, as demonstrated in this review, a significant number of factors exclusive to individual patients can influence help-seeking behaviour. In this respect, appropriateness is also defined subjectively by the patient. Jones (2011) suggests that healthcare providers should seek to improve care options rather than attempt to influence patient help-seeking behaviour. Perhaps services should therefore aim to educate patients through targeted campaigns, whilst simultaneously seeking to better understand patient requirements, and align services accordingly.

Similarly, few articles outlined how admission avoidance was defined. Coates (2013) was the only study that explored this in detail, and outlined that non-conveyance of a patient might not necessarily result in an avoided hospital admission, either due to inadequate use of referral pathways or subsequent medical need. This review has highlighted a universal lack of clarity regarding how successful admission avoidance is measured, and since this assessment is pivotal in evaluating adequate use of pathways, further clarity should be sought by ambulance services.
Conversely, almost all material discussing frequent users provided clear definitions of what was considered frequent use of services (Dent, Hunt & Webster 2010; Smith & McNally 2014; Scott et al, 2013; Edwards et al, 2014).

Several factors influencing patient behaviour in the context of inappropriate use were identified. A number of articles highlighted risk-averse behaviours by both patients and carers when dealing with minor illnesses due to misconceptions of condition urgency. In relation to chronic illnesses, patients demonstrated a reluctance to temporise symptoms, and often sought out the most immediate form of assistance. Material suggested that these behaviours were driven by misconceptions over the seriousness of conditions, in addition to a perceived lack of available alternatives.

Sanctioning of help-seeking behaviours by carers and relatives was an additional reoccurring theme, and interpersonal influence was found to exacerbate inappropriate use in most circumstances. Reviewed material demonstrates that patient education, whilst an important consideration, only accounts for a partial driver of patient behaviour. A large percentage of influence can be attributed to patients’ perception of barriers to alternative care. Strategies to reduce inappropriate use should aim to improve patient access to alternative care, whilst also improving education and raising awareness of community services.

It is well established that areas of social deprivation and poorer demographics suffer with increased health issues (National Institute for Health and Care Excellence 2012; Royal College of Nursing 2012), and this review furthermore found significant evidence to suggest that patients in this demographic may also significantly contribute towards inappropriate use (Agarwal et al, 2011; Association of Ambulance Chief Executives 2011; Scott et al, 2013; O’Cathain et al, 2013; Edwards et al, 2014; Smith & McNally 2014). Whilst the individual clinician should take caution in stereotyping patients, the implications for wider healthcare services in response management and healthcare promotion appear to be evident.

In relation to healthcare access, two dichotomous issues provide equal contribution to inappropriate use of emergency services. A perceived barrier to community care services was a reoccurring theme throughout a significant number of articles (Agarwal et al, 2011; Booker, Simmonds & Purdy 2013). This was combined inversely with the ease of access to ‘999’ and ED services, as well as unanimously positive patient experience using these services. It was furthermore suggested that barriers to non-urgent community care were not limited to patients. A number of articles highlighted that prehospital clinicians often encountered problems when attempting to refer patients unsuitable for A&E transport (NHS England 2013; O’Hara et al, 2014).

Whilst barriers to GP services were not explored in detail in this review, there is reasonable evidence suggesting that demand for these services is also increasing in line with other urgent and emergency care services (NHS England 2013). A review of current community care paradigms in the UK could be beneficial in establishing whether or not reform is required to meet evolving patient needs. There has been recent political suggestion that a solution may be found by bringing OOH care into the direct control of ambulance trusts (Roberts 2015).

The importance of multidisciplinary collaboration was emphasised universally across the majority of articles. Fragmentation of healthcare services was unanimously highlighted as a significant contributor to inappropriate ED attendance. There appears to be national inconsistency in the availability of alternative services (O’Hara et al, 2014), in addition to variation in prehospital awareness of available resources (National Audit Office 2011; O’Hara et al, 2014). The National Audit Office (2011) highlights that ambulance trusts are inconsistent in keeping directories of available referral pathways.

There is sufficient evidence to suggest a significant lack of collaboration, both between multidisciplinary services and between local trusts (NHS England 2013; Edwards 2014). Since this fragmentation affects so many factors of appropriate use, including patient and clinician behaviour and organisational management, it is reasonable to consider this to be the most significant finding of this review. Further research into the causes of systemic healthcare fragmentation, and proposals for reform should be considered of the utmost importance in addressing increasing demand and appropriate use of NHS services.

Internal healthcare factors were not limited to issues accessing alternative pathways. Service culture and clinical behaviours were also found to significantly contribute to inappropriate use of services (NHS England 2013; Newton et al, 2013; O’Hara et al, 2014). Oversensitive triage was observed at multiple stages of assessment, due to a combination of organisational and educational factors. Oversensitive telephone triage was also highlighted as a potential contributor to inappropriate ambulance dispatch (Turner et al, 2013).
Studies showed that clinicians with greater experience, and specialised training, demonstrated greater levels of confidence in utilising referral pathways, and subsequently lower levels of over-triage. If the ambulance service is to continue along its current trajectory establishing itself as a signposting service (National Audit Office 2011), further investment must be made in specialised clinical roles and education of staff at all hierarchal levels. Established literature suggests that specialised prehospital roles are still nationally inconsistent (National Audit Office 2011; O’Hara et al, 2014), and standardisation would be beneficial in realising their full potential.


Appropriate usage is a poorly defined concept in healthcare, and whilst it may be argued that appropriateness is a subjective term, rationales for defining users as inappropriate are consistently omitted. Healthcare services cannot expect to observe appropriate use of channels without clarification of what this looks like. Further effort should be made to provide objective guidance to both patients and clinicians.

Patient education and socioeconomic status contributed to patient help-seeking behaviour. However, healthcare access and framework issues influenced much of this behaviour. Perceived and tangible barriers to healthcare, combined with situations of perceived urgency, prompted the use of more immediate healthcare channels, contributing heavily to inappropriate use. This was reflected in prehospital clinicians making conveyance decisions. Articles suggested that lack of confidence and organisational support also prompted disproportionately risk-averse behaviour from ambulance staff.

Fragmentation of multidisciplinary services was a superordinate and reoccurring theme throughout this study. In this respect this review has demonstrated the fundamental link, not just between ambulance and ED services, but also between all multidisciplinary healthcare services. Since many patients have a diverse and complex range of healthcare requirements (Knowles, O’Cathain & Nicholl 2010; Edwards et al, 2014), service providers are dependant on one another to ensure that users travel adequately and appropriately through channels. This review demonstrates that no single service can thrive in isolation, and that the collaboration of collective services is the most fundamental aspect of improving health services and the way patients access them. Whilst success is dependant upon the collective effort of wider multidisciplinary services, this review has shown the ambulance service to be in an ideal position to influence how patients access care, and how services interact with one another.

Edward Liscott, former Paramedic Practice BSc(Hons) student


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An investigation into the use of humour among Paramedics as a factor in coping with stress and an element affecting resilience against burnout. A Literature Review


The word ‘Humour’ originates from the Latin for ‘fluid’ (Buxman 2008). Historically it was believed that the body contained four ‘humours’ (Blood, Phlegm, Yellow Bile and Black Bile), which governed a person’s health (Scott 2007). Today, though humour is considered ‘the quality of being funny’ (Collins English Dictionary 2011) there is no universally accepted definition (Buxman 2008; Moran 1990). Humour has a multidimensional value in healthcare (Beck 1997, 346); to help calm patients (Beck 1997), as a stress coping strategy (Mildenhall 2012), educational tool (Baid and Lambert 2010), and for group cohesion (Watson 2011).
The question of what affect different types of humour and different humour styles might have upon stress coping strategies is a significant one (Dyck and Holtzman 2013); especially for healthcare (Moran and Massam 1997). The aim of this literature review is therefore to analyse what is currently known in this area, highlighting aspects relevant to paramedic practice and possibilities for future research.


In order to achieve the aim of the study a systemic literature review was conducted. Initial searches of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, NHS Evidence, PubMed, ScienceDirect and Google Scholar databases using the keywords: burnout’ AND ‘paramedic’ OR ’emergency medical personnel’ OR ‘EMT’ OR ‘prehospital’ OR ‘pre-hospital‘, ‘resilience’ AND ‘paramedic’ OR ’emergency medical personnel’ OR ‘EMT’ OR ‘prehospital’ OR ‘pre-hospital‘, ‘humour’/ ‘humor’ AND ‘paramedic’ OR ’emergency medical personnel’ OR ‘EMT’ OR ‘prehospital’ OR ‘pre-hospital‘. The Boolean operators AND and OR were incorporated to combine search terms and focus results in the relevant area under consideration (Hart 2005). American/English spelling adaptations were included to locate all relevant literature (Moule and Goodman 2009). Searches yielded a significant number of studies but not all were available in full text. Those giving only abstracts were examined to see if they had noteworthy relevance; where found to, alternative avenues were investigated to acquire the full text. Some were obtained through online libraries via Google Scholar. Others, unavailable without payment, were excluded from the review. In order to conclude to the most suitable and narrow results the following inclusion and exclusion criteria were used:

  • Primary research: written by the person who developed the theory or conducted the original research (Polit and Beck 2006)
  • Published in English
  • Peer reviewed: research examined for bias or inappropriate subjectivity by the researcher’s peers or colleagues (Holloway and Wheeler 2010)
  • Free to Access

Due to the relative infancy of research into burnout (Felton 1998) and the older study of humour use (McCreadie and Wiggins 2008) no year of publication boundaries were set; resulting in the discovery of research which significantly informed this review. Additionally, worldwide parameters were allowed to investigate whether use of humour might uncover research with cultural factors relevant to the diversity of healthcare workers in Britain. Though people from ethnic minorities made up only 2% of ambulance staff in 2005 (National Guidance Research Forum 2005) it could be argued that paramedics engage with many healthcare workers in and out of the NHS as part of their work, making this consideration initially relevant. However, as only a limited number of studies, of minimal relevance were uncovered this review concentrates on first world research.

Secondary sources ‘can provide rich data’ (Munhall 2007, 382), however, they are only used where primary research was unobtainable and then limited to discussion areas or additional reference support. This is because secondary sources are one author’s commentary upon another author’s primary research, which can raise concerns over interpretation or bias (Macnee and McCabe 2008).

The Journal of Paramedic Practice was manually searched (due to online inaccessibility) with one article uncovered, aiding discussion elements.
Data saturation ‘indicates that everything of importance to the agenda of a research project will emerge in the data and concepts obtained’ (Holloway and Wheeler 2010, 146). This point was considered reached after repeated searches revealed the same articles closest to the research question.

Qualitative research studies the meaning people give to phenomena (Parahoo 2006), whereas quantitative research investigates ‘phenomena lending itself to precise measurement’ (Polit and Beck 2010, 565). The framework of Lobiondo-Wood and Haber (2002) (appendix 2) for critiquing qualitative and quantitative research was used to critique the three main studies considered central to the research question. Additional research was identified using a snowballing technique – where references in one study lead to locating works by other authors (Polit and Beck 2010).


Review of the research uncovered three main themes:

  1. Burnout: a condition experienced by paramedics
  2. Humour: a factor in stress relief and resilience
  3. Humour use by paramedics

Burnout: a condition experienced by paramedics

Originally used to describe the cessation of a jet engine, Felton (1998) additionally notes that in the 1970’s burnout was first applied to humans by psychologist Herbert Freudenberger. Freudenberger studied how healthcare personnel he worked with changed from being passionate about their job to becoming distant and apathetic; describing themselves as ‘burnt out’ (Ruysschaert 2009). Building on Freudenberger’s work, Maslach and Jackson (1981) published their research into the measurement of burnout, which became seminal for subsequent studies.
Burnout produces a combination of emotional exhaustion, de-personalisation, and reduced personal accomplishment (Maslach and Jackson 1981) being most frequently found among ‘human services professionals, particularly in healthcare’ (Felton 1998, 237). Chase (2014, 1) proposes that ‘no one burns out who wasn’t on fire to begin with’, suggesting burnout is peculiar to people with high expectations of themselves. Maslach and Leiter (2005) agree, proposing that idealists, perfectionists and those with a strong sense of purpose are most at risk. When ideals of relieving suffering, and expressing compassion, are thwarted by time or circumstance a sense of failure and inadequacy can lead to chronic stress and burnout (Chase 2014). The effect of burnout may include physical and emotional exhaustion, increased levels of anger, headache, insomnia, chronic hypertension, gastrointestinal complaints, immune dysfunction, infertility, sleep disorders (Felton 1998; Sophianopoulos, Williams & Archer 2012) as well as higher rates of alcoholism, drug abuse, increased smoking and caffeine intake and coronary heart disease (Frank and Ovens 2002).

Nirel et al (2008) identifies lack of administrative support, long hours, poor work / life balance, and poor salaries as causes of burnout in paramedics particularly. Sophianopoulos, Williams & Archer (2012) add shift work to this list. The impact of burnout upon paramedic’s families is also noted by Regehr (2005), significantly affecting the quality of interpersonal relationships. Increased levels of depression were noted by Griner (2013), with increased percentages of suicidal ideation acknowledged by Sterud et al (2008).

Much literature on burnout makes mention of Maslach and Jackson (1981), Griner (2013) noting burnout is usually measured in healthcare workers using Maslach’s Burnout Inventory (MBI) developed from this research. MBI is a self administered questionnaire which notes a range of responses to an individual’s feelings about their work (Kashka, Korczak & Broich 2011).

‘The Measurement of Experienced Burnout’ by Maslach and Jackson (1981) was first presented in the peer reviewed Journal of Occupational Behaviour, published by Wiley since 1980 ( The authors acknowledge use of qualitative data drawn from other researchers, citing: Freudenberger (1974; 1975), Ryan (1971) and Wills (1978), as well as previous personal research (Maslach 1976), and collaborative work with Pines (1977), however no reference is made to any literature review being conducted. This is possibly due to the infancy of research into burnout at the time (Felton 1998) or that some researchers prefer a brief overview rather than comprehensive literature review to set their study in context (Polit and Beck 2004). Additionally, ethical considerations are not mentioned, though it is unlikely researchers would neglect the basic principles of safeguarding participant’s rights and ensuring their safety (Parahoo 2006). Furthermore, footnotes acknowledge the study was supported by a Bio-Medical Sciences grant, which is awarded only after submission of an application showing all research considerations have been covered (Polit and Beck 2004). Two sample groups were drawn from a range of human services occupations across America including: Physicians, Police, Psychiatrists, Nurses, Social Workers and Counselors. Qualitative data was gathered through semi-structured interviews – presenting a set of questions allowing for individual responses but leading to similar data from participants (Holloway and Wheeler 2010), and quantitative data through questionnaires – a means of collecting specific, measurable data (Holloway and Wheeler 2010). How participants were recruited is not recorded. An initial 47 item questionnaire concerning ‘feelings and attitudes about work’ was compiled with each statement rated on two dimensions: Frequency and Intensity. An answer range of 1-7 gave options between ‘never’, to ‘every day’. This questionnaire was initially administered to 605 people – being a large enough group to be representative of the whole 1025 member sample (Polit and Beck 2010).

Four factors were discovered from the data and titled: ‘Emotional Exhaustion, ‘De-personalisation‘, ‘Personal Accomplishment’ and ‘Involvement’. The fourth factor, though appearing consistently in the data was rejected as a subscale due to its eigenvalue ‘being inconsistent with reliability’ (Maslach and Jackson 1981, 104).

Since publication MBI has been tested by numerous researchers; Schaufeli and Enzmann (1998), cited by Glasberg, Eriksson & Norberg (2007) suggest 90% of empirical studies into burnout now use MBI, giving credence to its dependability. MBI has also been used in organisational settings other than healthcare, including a telecommunications company, pension company and insurance company (Gonzalez-Roma et al 2006) increasing confidence in the transferability of MJ findings.

MJ found that results due to age varied, with younger people scoring higher risk of burnout than older – this is potentially significant when compared to McAlister and McKinnon (2009) who found similar factors in their study of student and qualified paramedics in Australia. The suggestion of Gayton and Lovell (2012) that healthcare workers with longer service owe their resilience to an element of natural selection is also interesting to note in light of this. Married workers were found to have lower risk of burnout than single or divorced workers – possibly equated to the beneficial factor of greater social support noted by Gustafsson et al (2010) and Dyrbye et al (2010).

MJ conclude with the desire that MBI may lead to greater understanding of burnout, ‘influencing future job training, recruitment and design to alleviate the problem’ (Maslach and Jackson 1981, 112); its widespread adoption by researchers (as mentioned above) suggests some accomplishment of this.

Stress is a significant issue within the NHS with an estimated 30% of all staff sickness absence related to it (NHS Employers 2012). Paramedics are particularly susceptible to levels of stress that can lead to burnout (Regehr and Millar 2007) and like other human service workers they use diverse strategies to cope with it (Hawkins 2008). The following chapter examines one strategy, humour use, which has a particular relationship to the emergency services (Charman 2013).

Humour: a factor in stress relief and resilience

Defined as ‘the ability to rebound from adversity and overcome difficult circumstances in life’ (McAlister and McKinnon 2009, 372), resilience is identified by researchers as key in the avoidance of burnout (Gayton and Lovell 2012).
Resilience consists of different factors including level of social support and personality (Grafton, Gillespie & Henderson 2010). However, of all factors highlighted in the development of resilience, the use of ‘humour’ stands out as a common theme (Essex and Benz-Scott 2008; Felton 1998; Grafton, Gillespie & Henderson 2010; Griner 2013; Ruysschaert 2009; Strumpfer 2003).

A ‘complex phenomenon, incorporating cognitive, emotional, behavioural, physiological and social aspects’ (McCreadie and Wiggins 2009, 1079), studies have lead to three basic theories of humour types:

The Incongruity Theory: developed by Kant (1724-1804) notes the ‘punch line’ is different from that expected, – humour being derived from this mismatch (McCreadie and Wiggins 2008).

The Superiority Theory: developed by Plato (427-347) and Hobbes (1588-1679) suggests we laugh at the failings of others to feel better about ourselves (Feagai 2011).

The Relief Theory: developed by Freud (1856-1939) suggesting humour releases suppressed emotions (Hawkins 2008).

Though examples of all three can be found in resilience strategies, Freud’s theory is perhaps more significant as it aims to relieve anxiety and transform negative feelings (Buxman 2008). In ‘The Joke and its Relation to the Unconscious’ (Freud 2002), Freud suggests humour provides an acceptable form for raising taboo subjects, additionally offering a means for ridiculing and dis-empowering people’s fears. The idea of weakening a threat or fear through ridicule is one also attested to by Downe (1999) and Obrdlik (1942); McGhee (2013) suggesting this is due to the increased sense of control humour brings to stressful situations. Henman (2001) corroborates, having found humour fundamental to resilience amongst American prisoners of war in Vietnam and survivors of concentration camps. The significance of this is not lost when considering the stresses of emergency care.

Kuiper (2012), and Dean and Major (2008) found humour helped medical personnel distance themselves from stressful situations; Chinery (2007, 1) calling humour a ‘buffer’ against stress.

Several researchers note claims over the positive health effects of humour (McCreadie and Wiggins 2008) including: reduction of anxiety, increased pain tolerance, improved respiration (Buxman 2008), lowering of blood pressure (McCreadie and Wiggins 2008) and release of endorphins (Fabry 2011; Feagai 2011). However, the most cited case is that of Norman Cousins whose recovery from Ankylosing Spondylitis is often claimed due to humour use (Moran and Massam 1997).

In Anatomy of an Illness, Cousins states: ‘ten minutes of belly laughter had an anaesthetic effect giving me two hours of pain-free sleep.’ (Cousins 1979, 15) Rowe and Regehr (2010), and Mahony (2000) are not alone in challenging Cousins’ claims after subsequent research left them unproven.

On claims of stress reduction Moran and Massam (1997) cite Martin and Lefcourt (1983) who suggest sense of humour does not lead to decreased stress but rather that humorous people generate more humour to cope with stress. To the claim that humour increases pain tolerance, Weisenburg, Tepper & Swartzwald (1995) discovered humour had only a distracting effect, with similar results produced in sample participants watching horror films as humorous films (Weisenburg, Tepper & Swartzwald 1995, 210).

Mahony (2000) found no empirical support confirming laughter triggers endorphin release and suggests watching fish is as effective as humour at lowering blood pressure (Mahony 2000, 2). Mahony’s conclusion: ‘Humour trait is more beneficial than humour state’ (Mahony 2000, 2).

Research into humour use identifies four distinct humour styles revealing how people communicate with others, cope with stress, and build resilience (Dyck and Holtzman 2013): Affiliative Style: strengthening interpersonal relationships whilst maintaining positive self-esteem (Olson et al 2005), Self-Enhancing Style: Having a humorous outlook on life, boosting self-esteem and buffering against stress (Olson et al 2005), Aggressive Style: ‘put down’ humour / sarcasm and ridicule – often having a negative effect on interpersonal relationships (Kuiper 2012), Self-Defeating Style: being excessively critical or ridiculing of one’s self in an attempt to enhance relationships (Kuiper 2012).

For building resilience and coping with stress, affiliative and self enhancing humour are considered positive, whereas aggressive and self-defeating styles are considered negative (Hawkins 2008).

As well as acknowledging humour styles have positive and negative effects, Dyck and Holtzman (DH) questioned whether social support and gender might be factors which further influence the effect of these styles on well-being. Their quantitative method gathered a sample of 826 students, 65.3% Female, 74.3% Caucasian; with 88.7% between age 18-22. Participants were recruited through the psychology research pool at two Canadian universities. A ‘convenience sample’ – those most easily available (Polit and Beck 2010; Holloway and Wheeler 2010), this sample could be accused of bias (Polit and Beck 2004) as they were drawn from students interested in psychology research and therefore not truly representative of all university students. Data was gathered using online questionnaires, results being subjected to bivariate analysis – a means of quantitatively analysing two variables to determine the relationship between them (Babbie 2009). Analysis revealed:

Affiliative Humour was:

  • The highest average score
  • associated with lower levels of depressive symptoms
  • associated with higher levels of life satisfaction
  • associated with higher levels of perceived social support

Self-Enhancing Humour was:

  • associated with lower levels of depressive symptoms
  • associated with higher levels of life satisfaction
  • associated with higher levels of perceived social support.

Aggressive Humour was:

  • significantly higher in males than females
  • not significantly associated with depressive symptoms, life satisfaction or levels of perceived social support.

Self-Defeating Humour was:

  • The lowest average score
  • associated with greater depressive symptoms
  • associated with lower life satisfaction
  • associated with lower levels of perceived social support.

DH suggest that affiliative and self-enhancing humour styles could be interpreted as more socially attractive and therefore act to increase a person’s social support, whereas aggressive and self-defeating styles could produce the opposite. However, they note a potential alternative explanation might be that social support has a controlling influence on humour styles and their affect on well-being. High social support might enhance the use of positive styles, and diminish the effect of negative styles; whilst lower social support may have the opposite effect.

The application of this study to the paramedic setting is interesting in that it suggests social support; gender and humour styles all have an effect on well-being and potential resilience levels. The Ambulance Service has been a traditionally ‘male’ dominated environment (Sterud et al 2008, Bennett et al 2004) with potential for steering humour towards aggressive styles, (possibly less beneficial for female staff). Levels of social support within the Ambulance Service have also been identified as significant in the area of burnout and resilience (Van de Ploeg and Kleber 2003). In the following chapter the issue of humour use by ambulance staff will be examined to consider its effect upon resilience to burnout.

Humour use by Paramedics

Rebuffing the idea that humour in healthcare is unprofessional, Dean and Major (2008) champion its value in aiding communication, managing emotion, team building and burnout avoidance. Furthermore, within emergency healthcare research a common theme is the use of ‘gallows humour’ (GH) for stress relief (Alexander and Klein 2001; Bennett 2003; Rosenberg 1991).
GH is often used at times of tragedy or death (Bennett 2003, 1259). Freud (2002) notes its use by individuals, but Obrdlik (1942), in a study of the Nazi invasion of Czechoslovakia, was one of the first to document its use by whole societies. Its use by groups in stressful work environments has since been acknowledged (Moran and Massam 1997).

Amongst many paramedics, GH is considered ‘the biggest coping mechanism we have’ (Villeneuve 2005, 8). Diminishing negative feelings by re-framing a horrific situation GH offers a defense in overpowering situations (Van-Wormer and Boes 1997); whilst ‘maintaining sanity under insane circumstances’ (Kuhlman 1988; cited in: Rowe and Regehr 2010, 449). Several researchers noted how paramedics use humour to develop their social support (Mildenhall 2012) and build group cohesion (Rowe and Regehr 2010).

A seminal, qualitative study into humour use by paramedics is Rosenberg (1991) ‘A qualitative investigation of the use of humor by emergency personnel as a strategy for coping with stress’, which compares humour use by experienced and student paramedics, noting the development and adaptation of humour through exposure to clinical experience and exploring how changes in humour use may be ‘an adaptive method for coping with stress’ (Rosenberg 1991, 197).

Longitudinal research – ‘examining changes in a group over time’ (Burns and Grove 2001, 251), was incorporated in studies of 10 (ultimately 9) student paramedics from a convenience sample of 37. Known as the ‘pre/post trained group’, they were firstly interviewed before training, and then interviewed again after training.

A second group of 10 ‘experienced’ paramedics with 1-7 years experience were additionally recruited and interviewed once only. Their results, compared with the first group, provided cross sectional data for the study. Cross sectional research gives data from ‘more than one group of subjects at various stages of development, simultaneously’ (Burns and Grove 2001, 252).

Though participant numbers were small, data saturation – where no new data is uncovered (Polit and Beck 2010) was highly probable as the groups were representative of the ‘student’ and ‘experienced’ populations. Data was gathered using a structured interview – ‘the same questions, in same order, with same response options’, (Polit and Beck 2004, 349), but with open ended questions – ‘giving freedom to respond in narrative fashion’ (Polit and Beck 2004, 349). Inductive analysis – taking specific facts to form general theory (Macnee and McCabe 2008), ‘without the restraints imposed by structured methodologies’ (Thomas 2003, 2), was employed to make maximum use of the data; enabling recurrent themes to be categorized and counted.

Charman (2013); Mildenhall (2012); and Rowe and Regehr (2010) acknowledge the same with regard to humour building group cohesion, teamwork and social support.

Context of EMS humour: The ‘experienced’ paramedics stated that ‘they could not share the humour they used at work with family or friends’ (Rosenberg 1991, 199). Bennett (2003) suggests that because humour exists within a certain culture, what is funny to some will not be to others. Those ‘outside’ the group (including family and friends) may be repelled by GH because they ‘cannot fully comprehend the reason for its origin’ (Rowe and Regehr 2010, 456).

Goffman (1959) presents the concept of regions of acceptable behaviour within society. Applied to humour use in healthcare, this proposes that emergency workers have ‘Frontstage’, ‘Backstage’ and ‘Offstage’ environments which moderate their behaviour (Williams 2013a). As part of the unwritten rule of GH use, it is only acceptable in the ‘Backstage’ environment of either the crew room or at an incident scene where no non-emergency personnel are present (Williams 2013a; Watson 2011; Mildenhall 2012). GH is never appropriate in the ‘Frontstage’ environment where patient relatives look to paramedics for support (McCarroll et al 1993), and is strongly discouraged in the ‘Offstage’ environment – at home or off duty when paramedics are with relatives and friends, as they are ’outside’ the circle for understanding the nature or origin of the humour (Rosenberg 1991).

Purpose of Humour use: All participants, except three from the pre/post group, stated they used humour as a coping strategy; with the entire experienced group rating it higher in importance as a strategy than any of the pre/post group. The students emphasised the tension relieving aspect of humour use after a bad day which is also acknowledged by Moran (1990), who considers humour more associated with reducing stress after an event rather than during (Moran 1990, 368). In contrast, the experienced group strongly emphasised the cognitive and emotional refocusing power of humour; as noted by Buxman (2008), Freud (2002) and Kotthoff (2006). Rosenberg therefore suggests humour use becomes a deepening or maturing stress defense for paramedics.


This review identified three main themes: ‘Burnout: a condition experienced by paramedics’, ‘Humour: a factor in stress relief and resilience’, and ‘Paramedic use of humour’.
Chronic stress can lead to the three elements of burnout: emotional exhaustion, de-personalisation and diminished sense of accomplishment (Maslach and Jackson 1981). In healthcare this manifests as deterioration in the quality of care, high job turnover, absenteeism and increased health issues for those affected (Maslach and Jackson 1981). As paramedics are among those with the highest risk of burnout (Regehr and Millar 2007), this carries implications both individually and organisationally.

Implications for Paramedics
Maslach and Leiter (2005) and Chase (2014) suggest that a contributing factor in burnout of healthcare workers is the imbalance between the care they desire to give and the care they are able to give. For paramedics, shift work, pressure to meet targets, abuses of the service by some people, and poor work/life balance are elements which affect this (Mildenhall 2012; Nirel et al 2008; Regehr and Millar 2007; Sophianopoulos, Williams & Archer 2012).

Maslach and Leiter (2005) suggest that giving time to stress relieving pursuits such as sporting activities, hobbies and social relationships, enable individuals to defuse the stresses of work which lead to burnout. However, a consequence of shift work is that partners and friends may be at work themselves when paramedics are off duty, with repercussions for social relationships (Harrington 2001). In contrast, Sophianopoulos, Williams & Archer (2012) suggest that families of shift-workers often adapt to their situation, becoming more resilient. Further research in this area might reveal factors contributing to positive social adaptation, of benefit to paramedics.

Access to information on their patient’s outcome is a source of stress for some paramedics (Regehr and Millar 2007); the lack of such information leading to concerns over personal competency (Witmore 2013). Access to patient information is governed by the Data Protection Act (1998) making confidentiality a legal requirement in NHS employment contracts (Department of Health 2003). Legislation allowing paramedics access to information on their patient’s outcome would help reduce incident related stress and encourage reflection (Bishop 2013), potentially improving staff well-being and patient care (Okougha 2013).

Organizational implications
The Health and Safety at Work Act (1974) requires employers to do everything reasonably practicable to protect the health, safety and well-being of their employees, including minimising the risk of stress related illness. As an employer, ambulance Trusts are subject to this legislation. Occupational health departments aim to provide employees access to counseling services, post incident de-briefing opportunities and peer lead support groups (NHS Employers 2012). Additionally, the Boorman Review (Department of Health 2009) recommended the establishment of staff stress management initiatives to further address well-being issues.

The reluctance of paramedics to disclose the full stresses of their work to those in ‘off-stage’ environments means they rely on ‘backstage’ environments (crew-rooms) for relieving the pressure (Williams 2013a). With the introduction of ‘Make Ready’ (SECAmb 2010) where vehicles are re-stocked by contractors rather than crews; and the increased deployment of crews to stand by points, ‘backstage’ time could be significantly reduced. Though possibly beneficial for productivity this removes a potential stress relief outlet for paramedics (Mildenhall 2012). Research into the impact of these initiatives, as well as into ways ambulance services might be proactive in initiating positive approaches to staff at risk of burnout could contribute to a reduction in the strain placed upon services due to absenteeism.

Humour: a factor in stress relief and resilience
The potential of humour as a positive element within healthcare is acknowledged by numerous researchers (Dyck and Holtzman 2013; Rosenberg 1991; Scott 2007; Shepherd and Wild 2014; Watson 2011).

Of the three main Humour Theories (Incongruity; Superiority; Relief), Freud’s ‘Relief Theory’ has the strongest association to humour use by paramedics, suggesting humour can bring a culturally acceptable means of releasing suppressed emotion, dis-empowering a potential threat and re-framing unpleasant experiences into more emotionally and cognitively manageable ones (Buxman 2008; Downe 1999; Henman 2001; McGhee 2013). Mahony (2000, 2) considers ‘humour trait more beneficial than humour state’, a view given weight by studies into humour styles, whereby ‘affiliative’ and ‘self-enhancing’ styles have been found to have a positive influence upon resilience to stress and burnout; whereas ‘aggressive’ and ‘self-defeating’ styles can have a negative effect (Dyck and Holtzman 2013; Stieger et al 2011).

Implications for individuals and organizations
Dyck and Holtzman note how ‘aggressive’ humour styles are more common amongst men; whilst Mahony (2003); and Williams (2012), acknowledge that ambulance services are traditionally male dominated. Citing the Office of National Statistics, Williams (2012) highlights that in 2010 there were ‘approximately 13,000 male paramedics in the UK whilst the number of female paramedics was too small for a reliable estimate’ (Williams 2012, 370). However, figures for registered UK paramedics in November 2013 indicate 7667 female paramedics compared to 12451 male (HCPC 2013). These figures still reveal a predominantly male profession.

Though ‘aggressive humour style’ might not significantly affect male resilience levels, as Dyck and Holtzman (2013) hypothesise, the higher percentage of male paramedics may mean a dominant aggressive humour style exists culturally. As numbers of female paramedics rise the humour culture they encounter may, therefore, have implications for their resilience levels.

Humour use by Paramedics
Whilst humour use for calming patients and relieving stress has been noted, of particular interest is paramedic’s use of ‘gallows humour’ (GH).

Gallows Humour
Helping to re-frame stressful situations, making them more emotionally manageable (Van-Wormer and Bows 1996), GH is most often used in times of tragedy, oppression or death (Bennett 2003; Freud 2002; Moran and Massam 1997; Obrdlik 1942). Its use today being particularly prolific among emergency services personnel (Charman 2013; Mildenhall 2012; Watson 2011).

Rowe and Regehr (2010) point out that GH often appears in general society after a major disaster, suggesting GH offers a means of putting tragedy into perspective. The fact that GH use is prevalent among paramedics (who potentially encounter more traumatic situations than those employed outside emergency, medical or armed forces careers) is therefore understandable (Chase 2014).

Implications for Paramedics
The question of how humour use, particularly GH, relates to professionalism is an obvious one. The Health and Care Professions Council: Standards of conduct, performance and ethics (2012) highlights the expectation that registrants will deal respectfully towards service users, showing integrity, and the highest standards of personal conduct, whilst avoiding any action that would bring their profession into disrepute (HCPC 2012, 3). The potential for inappropriate humour use to breach these standards is strong. However, Rosenberg (1991); Rowe and Regehr (2010); and Williams (2012) indicate that tight boundaries for cultural humour use exist within ambulance services, where GH particularly is considered taboo outside specific environments, or with those outside the accepted group.

The concept of ‘Frontstage’, ‘Backstage’ and ‘Offstage’ environments (defined by whether any non-emergency personnel are present), has been suggested by Goffman (1959); Rosenberg (1991); Watson (2011) and Williams (2012). For paramedics, the ‘backstage’ environment, such as the station crew-room or ambulance vehicle cab, is considered the only one where GH is sanctioned. This self regulated cultural code of conduct would seem to act as a strong deterrent to breaches of professionalism, though cannot guarantee against them. The potential for GH between paramedics to be overheard by non-emergency personnel at the scene of a traumatic event is reasonably high and paramedics should be vigilant in guarding against it.

Implications for the future progression of the Paramedic profession
Literature considered in this review suggests the presence of a humour culture within the Ambulance Service that new recruits are socialised into (Rosenberg 1991). Furthermore, Essex and Benz-Scott (2008); McAlister and McKinnon (2009); Rosenberg (1991) and Villeneuve (2005), observe that recognition of the value of humour use as a coping strategy increases with clinical experience and years of service.

The role of socialisation in conforming new members of a group into cultural norms is a recognised phenomenon (Giddens and Sutton 2013). However, the question of whether socialisation into all aspects of ambulance humour culture is helpful or desirable within the modern Ambulance Service is potentially controversial. The benefits of appropriate humour use for relieving stress are attested to by many and not considered unprofessional (Dean and Major 2008). However, the more negative elements of humour culture such as overly aggressive humour styles and ‘put down’ humour, which Berk (2009) suggests is strongly associated with medical professions, may be unhelpful to some staff as the profession progresses.

Conclusion and Recommendations

This literature review has investigated the use of humour by paramedics as a factor in coping with stress and an element affecting resilience against burnout. Paramedic practice can be acutely stressful at times (Halpern et al 2012) though lower levels of chronic stress also exist within the role (Mildenhall 2012). The combination of this stress can lead to the emotional exhaustion, de-personalisation and loss of personal accomplishment that characterises burnout (Maslach and Jackson 1981).
Humour use has been identified as a factor in resilience and as a coping strategy against burnout among paramedics (Rosenberg 1991), being used as a distancing and re-framing technique in challenging situations and for fostering socialisation and group cohesion (Charman 2013). Its role in the development of student paramedics is also significant (Dean and Major 2008; Rosenberg 1991).

  • Recommendations for future research and practice as a result of this review include:
  • Investigating the effect of increases in female clinical staff numbers on the humour culture and staff resilience levels within the Ambulance Service.
  • Examining the impact of initiatives such as ‘Make Ready’ and reduced time at base stations upon paramedic’s resilience to burnout.
  • Exploring the socialisation process of student and newly registered paramedics into the Ambulance Service; the role humour plays in this and its effect on the development of group culture.

Chris Storey Paramedic Practice BSc (Hons) student


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