Where next for the paramedic profession? An ethnography of work culture and occupational identity.

The paramedic profession, along with the broader structure and mission of NHS emergency ambulance provision, is undergoing significant but rather undefined change. The clinical scope of the paramedic role has broadened, and the opening of new patient pathways has enabled a broader range of treatment and referral options for attending ambulance crews. Ambulance trusts have moved to an all-graduate intake for new paramedics, and significant advances have been made in establishing the classic steps of a 'professionalization project' (such as the growth of the College of Paramedics, the development of peer-reviewed practitioner journals, and the introduction of advanced paramedic roles.) Some of these changes are contentious, however, and many of the fundamentals of ambulance work and occupational culture remain unchanged to a significant degree. Long-standing problems persist around low staff morale, high levels of sickness-related absence, lack of capacity, limited resources and support, the dominance of a 'targets culture', and a lack of working trust between 'management' and 'roadstaff.' Working life 'on the road' is demanding and the emergency ambulance field is a challenging environment for the pursuit of a professionalization project. This paper provides insights from a sociology of work perspective into the everyday work culture of ambulance services. Based on qualitative interviews and ethnographic observation of ambulance crews and of mid-level ambulance trust managers, the paper provides an in-depth exploration of the culture of everyday working life in (anonymized) ambulance trusts. We identify several broad conceptions among staff as to the essence and purpose of emergency ambulance provision, of ambulance trusts as employers, and of the goals and potential pitfalls of the professionalization project. The paper thus explores the multifaceted meanings of 'professionalism' and considers the broad challenges facing the profession at large and NHS trusts as employers as both confront unsettling forms of change.