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Tragic choices in providing paramedic care during the 2020 COVID-19 Pandemic: An Evolved Grounded Theory ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2021-048677
Article Type: Original research
Date Submitted by the 20-Jan-2021 Author:
Complete List of Authors: Rees, Nigel; Welsh National Ambulance Service NHS Trust, Pre-Hospital Emergency Research Unit Smythe, Lauren; Welsh National Ambulance Service NHS Trust, Pre- Hospital Emergency Research Unit Hogan, Chloe; Welsh National Ambulance Service NHS Trust, Pre- Hospital Emergency Research Unit Williams, Julia; University of Hertfordshire, School of Health and Social Work
COVID-19, ACCIDENT & EMERGENCY MEDICINE, Organisation of health Keywords: services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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1 2 3 4 Tragic choices in providing paramedic care during the 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 2020 COVID-19 Pandemic: 7 8 9 An Evolved Grounded Theory 10 11 12 13 *Nigel Rees, PhD1. Lauren Smythe MSc1. Chloe Hogan MSc1 Julia Williams PhD2 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 1. Pre Hospital Emergency Research Unit (PERU), Welsh Ambulance Services NHS Trust (WAST), 40 41 Institute of Life Sciences, Swansea University, Swansea, Wales, 42 2. Paramedic Clinical Research Unit (ParaCRU), University of Hertfordshire, Hatfield, 43 Hertfordshire, United Kingdom 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 *Corresponding author: email [email protected] 53 54 55 56 57 58 59 60
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1 2 3 Abstract 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 Objective To explore Paramedic experiences of providing care during the 2020 COVID-19 7 8 pandemic and develop theory in order to inform future policy and practice. 9 10 Design A qualitative study using Constructivist Evolved Grounded Theory methodology. 11 12 One-to-one semi-structured interviews were conducted using a general interview guide. A 13 14 Voice over Internet Protocol (VoIP) was used with the internet carriage service Skype™. 15 16 • Setting The study was conducted between March 2020 and November 2020 in the Welsh 17 18 Ambulance ServicesFor NHS Trust peer (WAST) review UK which serves only a population of three million. 19 20 • Participants Paramedic participants were recruited through a poster circulated by email and 21 22 social media. Following theoretical sampling, twenty Paramedics were consented, enrolled 23 into the study and interviewed. 24 25 26 Results The following four categories emerged: Protect me to protect you, Rapid disruption 27 28 and adaptation, Trust in communication and information and United in hardship. The Basic 29 Social Process in paramedic experiences of providing care during the 2020 COVID-19 30 31 pandemic was recognised to involve Tragic Choices and was conceptualised through an 32 33 Evolved Grounded Theory which involved Tragic personal & professional choices, Tragic 34 35 organisational choices and Tragic societal choices. 36
37 Conclusions http://bmjopen.bmj.com/ 38 39 The COVID-19 pandemic is the biggest challenge in modern times to have faced providers of 40 41 healthcare globally. Paramedics are at the forefront of the UK pandemic response, and this 42 43 Evolved Grounded Theory richly articulates the range of issues faced by them in terms costs 44 endured, prices paid, the value we assign to these issues and the tragic nature of choices
45 on October 1, 2021 by guest. Protected copyright. 46 made. The epidemiological and virological battle continues to analyse and understand the 47 48 causes, effects and treatments for COVID-19 and other viruses. We do not yet know how 49 50 effective these efforts will be? But despite this, within the catastrophic societal, professional, 51 personal and organisational impact of such pandemics in a world of competing and 52 53 conflicting decisions and resources Tragic Choices have to be made and implicit prices must 54 55 be placed on lives saved. 56 57 Registration Integrated Research Application System [IRAS ID: 282623]. 58 59 60
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1 2 3 Strengths and limitations of this study: 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 The study was set up rapidly in one UK ambulance service very early in their 7 8 response to COVID-19. This was a unique opportunity to capture experiences of 9 Paramedics providing care as the pandemic unfolded. 10 11 A rich Evolved Grounded Theory has been constructed on the tragic choices in 12 13 providing paramedic care during the 2020 COVID-19 Pandemic, but is limited by 14 15 involving a small sample and being conducted in one ambulance service. 16 Remarkable consistency and agreement was found throughout analysis, member 17 18 checking andFor previous peer studies which review adds to the trustworthiness only and transferability of 19 20 our findings. 21 Using the VoIP of Skype™ was deemed a strength, especially in the context of a 22 23 pandemic due to social distancing. Technical difficulties did occur, and one recording 24 25 became corrupted. 26 27 The research team included insider researchers with three practicing paramedics and 28 whilst this may be considered a potential bias, we stated up front the constructivist 29 30 nature of evolved grounded theory and how the background of these researchers 31 32 added to the richness of the GT. 33 34 35 36
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1 2 3 Background 4 5 The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) the virus responsible BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 for COVID-19 was first reported in December, 2019 in China [1]. COVID-19 rapidly spread 8 across the world, qualifying as a global pandemic by WHO on March 11 2020. COVID-19 9 10 has affected 220 countries, areas or territories, with 54 558 120 confirmed cases and 1 320 11 th 12 148 deaths as of 11 Nov 2020 2]. In the UK plans prepared in the aftermath of the 2009 13 H1N1 global threat were enacted [3], which included the response from ambulance and wider 14 15 health services and also wider societal measures including isolation methods, closing schools, 16 17 businesses and self-isolation [4] 18 For peer review only 19 Prior to the COVID-19 pandemic, calls were repeatedly made for Health Care 20 21 Workers (HCWs) in the UK to ready themselves for such pandemics [5,6] which may involve 22 23 difficult and ethical challenging decisions shaped by the local context and cultural values [7]. 24 HCW’s face personal challenges and fears related to unemployment, isolation, contracting 25 26 disease, mortality, and infecting family [8-12], The COVID-19 pandemic presented a unique 27 28 opportunity to understand these issues from a UK paramedic perspective, and a program of 29 30 research was developed by our team to explore Paramedic Experiences of providing Care 31 during the 2020 COVID-19 Pandemic (PECC-19). We conducted an initial review of the 32 33 literature which found a paucity of published research concerning paramedics along with 34 35 many of the challenges reported above [13]The present paper reports the finding of a 36 qualitative study we conducted which aimed to explore Paramedic experiences of providing 37 http://bmjopen.bmj.com/ 38 care during the 2020 COVID-19 pandemic and develop theory in order to inform future 39 40 policy and practice. 41 42 Methodology 43 44 Strauss & Corbin’s (1998)[14] evolved form of GT methodology was used, which
45 on October 1, 2021 by guest. Protected copyright. 46 follows a constructivist perspective and accepts that people construct the realities in which 47 48 they participate and thus highlights the researcher–participant dyad and the co-construction of 49 50 data [15]. In Evolved GT, the researcher is a “passionate participant as facilitator of multi- 51 voice reconstruction” (Lincoln & Guba 2005 p. 196)[16]. Three researchers within this study 52 53 were practicing paramedics and provided (limited) frontline care during the 2020 COVID-19 54 55 pandemic which in turn facilitated insight, awareness and ability to bring meaning to the data 56 [17]. Such background does though have the potential for preconceived ideas and previous 57 58 encounters to influence the construction of the evolved GT, and to counteract this member 59 60 checking and reflexivity methods were employed.
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1 2 3 Methods 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 Data Collection 7 8 Interviews 9 10 One hour, one-to-one semi-structured interviews were conducted using a general interview 11 guide. The internet carriage service Skype™ was used, which is a Voice over Internet 12 13 Protocol VoIP (VoIP) [18]. VoIP was beneficial in the COVID-19 pandemic context as 14 15 paramedics are a scattered workforce, practicing social distancing during the study and this 16 17 approach minimised time needed away from clinical duties to participate. Interviews were 18 video recorded withFor memos taken,peer transcribed review verbatim and only checked for accuracy against the 19 20 recordings. 21 22 23 Data analysis 24 25 Analysis followed Strauss and Corbin’s (1998)[14] three levels of open, axial and selective 26 coding entered into NIVO 12 software to create a coding book. Open coding compared data 27 28 for similarities, differences and questions regarding emergent phenomena resulting in 29 30 identification of indicators; words or phrases of interest. Indicators were subsumed under 31 32 higher level headings known as concepts, which stand for the emerging phenomena. Axial 33 coding involved subsuming concepts into higher-level headings known as categories. 34 35 Selective coding also involved “explication of the story line” (Strauss & Corbin 1998, p. 36
37 148)[14] which involves identifying the Basic Social Process (BSP) at work, around which http://bmjopen.bmj.com/ 38 all other categories revolve. The BSP meaningfully and easily relates to all other categories 39 40 and should have clear and grabbing qualities [19] upon which to theoretical construct the 41 42 Evolved Grounded Theory (GT) through weaving all of the fractured data back together and 43 44 conceptualising the relationship among these three levels of coding. A second researcher
45 [CH] independently reviewed this coding. Participants also member-checked data analysis by on October 1, 2021 by guest. Protected copyright. 46 47 reviewing excerpts from the coding book and returning comments on evolving theory. 48 49 Reflective notes were made by researchers considering theory development and monitoring 50 51 the researchers’ influences on this process. 52 53 Ethical considerations 54 55 The study was submitted to the Integrated Research Application System [IRAS ID: 282623]. 56 57 NHS Research Ethical review was not required within Health Research Authority guidance 58 59 [20], but issues of an ethical nature remained which were observed by following the 60 Economic and Social Research Council [21] framework. Participants provided verbal and
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1 2 3 written consent. All data were collected and stored in accordance with GDPR (2018)[22] 4 5 regulations. We recognised staff may become emotionally upset during the research, and a BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 range of support was made available. 8 9 Setting and sampling: 10 11 The study was conducted between March 2020 and November 2020 in the Welsh Ambulance 12 13 Services NHS Trust (WAST) UK which serves a population of three million. Participants 14 15 were recruited through a poster circulated through email and social media. Information packs 16 were sent to participants containing a consent form to sign and return to the researcher; 17 18 confirmed verbally Forduring interview. peer Participants review were selected only using theoretical sampling 19 20 based on the characteristics of gender, age, experience, and educational development to 21 reflect the paramedic workforce. Confidentiality and anonymity was assured. 22 23 24 Patient and Public Involvement: 25 26 As this study was rapidly set up and due to the context of WAST responding to COVID-19 27 28 we did not involve patients or members of the public. We do however intend to present our 29 30 findings to public and patient groups. 31 32 Results 33 34 Twenty six paramedics responded to the poster call, six did not end up participating and a 35 36 final sample of twenty were consented and enrolled into the study. One paramedic was not
37 http://bmjopen.bmj.com/ 38 interviewed due to theoretical sampling and one of the interview recordings became 39 corrupted and not included in the analysis. Table 1. Includes characteristics about the sample 40 41 of paramedic participants. 42 43 44 Paramedic
45 on October 1, 2021 by guest. Protected copyright. EMS Self educational 46 Participant Gender Experience Age range Isolated development Interviewed 47 48 P01 Male >10 26-45 No Traditional training PILOT 1 - 09/04/2020 49 P02 Female 3 to 10 46-55 Yes Higher Education PILOT 2 - 09/04/2020 50 P03 Female >10 46-55 Yes Traditional training Interview 3- 16/04/2020 51 P04 Male >10 26-45 No Higher Education Interview 4 - 20/04/2020 52 P05 Female 1 to 3 26-45 yes Higher Education Interview 6 - 20/04/2020 53 P06 Female >10 46-55 No Higher Education Not Sampled 54 55 P07 Female 3 to 10 26-45 Yes Higher Education Interview 5 -20/04/2020 56 P08 Male 3 to 10 26-45 Yes Higher Education Interview 7 -23/04/2020 57 P09 Male 1 to 3 19-26 No Higher Education Interview 16 - 21/05/2020 58 P10 Female >10 26-45 No Higher Education Interview 10 - 30/04/2020 59 P11 Female >10 26-45 Yes Higher Education Interview 8 - 28/04/2020 60
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1 2 3 P12 Male >10 26-45 No Traditional training Interview 9 - 29/04/2020 4 P13 Female 3 to 10 26-45 Yes Higher Education Interview 15 - 20/05/2020 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 5 6 P14 Male >10 46-55 Yes Traditional training Interview 14 - 19/05/2020 7 P15 Female 1 to 3 26-45 Yes Higher Education Interview 12 - 05/05/2020 8 P16 Male >10 56-60 No Higher Education Interview 13 - 07/05/2020 9 P17 Male 1 to 3 Incomplete No Higher Education Interview 11 - 04/05/2020 10 P18 Male 3 to 10 26-45 Yes Higher Education Interview 17 - 27/05/2020 11 P19 Male 3 to 10 26-45 Yes Incomplete Interview 18 - 03/06/2020 12 13 P20 Male >10 46-55 Yes Traditional training Interview 19 - 02/07/2020 14 Table 1 Sample of paramedic participants 15 16 The following four categories emerged: Protect me to protect you, Rapid disruption and 17 adaptation, Trust in communication and information, United in hardship. The BSP in 18 For peer review only 19 paramedic experiences of providing care during the 2020 COVID-19 pandemic was 20 21 recognised to involve Tragic Choices and was conceptualised in the GT in fig 1 which 22 23 involved Tragic personal & professional choices, Tragic organisational choices and Tragic 24 societal choices: 25 26 27 Fig 1. Grounded Theory (GT): Tragic choices in providing paramedic care during the 2020 28 COVID-19 Pandemic 29 30 Category 1. Protect me to protect you 31 All of our paramedic participants except one expressed concern for themselves and 32 33 their families during the pandemic due to a perception of the risks their occupation posed. 34 35 “Not so much catching it myself, but bringing it home to my family”(P09) 36
37 http://bmjopen.bmj.com/ 38 They were concerned of risks to family members with underlying health issues revealing 39 40 internal conflict between their occupational role and the safety of their families. A wide range 41 of underlying conditions were reported including pregnancy, asthma, immunosuppression 42 43 [HIV negative] and leukaemia, and participants often mentioned concern for family members 44
45 from these vulnerable groups and their elderly relatives. on October 1, 2021 by guest. Protected copyright. 46 “my partner works as a frontline carer, he is immunosuppressed but is HIV negative”… “he 47 48 has got significant risks, but obviously with me working in the frontline, and him in frontline 49 aswell, one of the early fears were do we basically separate or do I basically separate from 50 him to reduce that risk. Whilst I would always do my job, I would never forgive myself if I 51 thought for one moment that I had brought something from the community and brought it 52 back home” (P08) 53 54 Paramedics told how practicing in this context was unlike anything they had experienced 55 56 before with an ever-present sense of fear and risk. 57 58 “I felt anxious going to work, I felt scared going to work, it’s scary to think you can go to 59 work and bring it home, that is not a nice feeling” (P12) 60
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1 2 3 All participants talked about front line HCW’s dying from COVID-19, and in April 2020, a 4 5 paramedic within the study area died from COVID-19. From this point on all of the BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 participants reflected on the death of their colleague, as shared by paramedic 14: 8 9 “We have [name] working here… its knocked it a bit closer to home again,….it’s had a 10 massive effect because he was such big character” (P14) 11 12 Powerful accounts were relayed of their sustained exposure and close proximity to patients 13 14 with COVID-19 symptoms. Paramedic 15 who contracted COVID 19 along with her partner 15 16 early in the pandemic, said prior to contracting COVID-19 she: 17 18 “was petrified really,For standing peer in a house review where someone isonly coughing and spluttering for half 19 an hour, 45minutes and then conveying them to hospital, which took another hour…..you are 20 21 in the back of the vehicle 2 meters by 1 meter… with a patient who is coughing virus into the 22 air potentially and I’m breathing that air in. so it was horrible really. (P15) 23 24 They reported attempts being made to mitigate the risks of working in this environment, 25 which involved changes in practice and provision of PPE. Such efforts however did little to 26 27 alleviate this fear-filled context, which seemed to influence their morale. Paramedic 15 was: 28 29 30 “really worried because I knew the masks didn’t fit me properly, so I was anxious and I felt a 31 bit demotivated to be in work, that I didn’t want to be there because every day I was going in 32 and it was a permanent risk really” (P15) 33 34 Paramedics in our study reported this environment of fear influenced many areas of their 35 36 lives, including changes to hygiene practices such as changing out of their uniform and
37 showering in work, avoiding visiting friends and relatives, and talking more openly on http://bmjopen.bmj.com/ 38 39 making preparations for their own death. They also reported a dramatic reduction in workload 40 41 and that people were avoiding care for fear of contracting COVID-19 which they felt was 42 43 influenced by the media and conversely increased emergency calls to assess people who 44 thought they had COVID-19.
45 on October 1, 2021 by guest. Protected copyright. 46 47 “There was a lot of fear among patients, which I can understand. You see a lot of death and 48 fearmongering on the news, there was a lot of fear among patients. But then that also led to 49 frustration amongst us on the road because we are going to patients who are phoning 999 50 because they have a bit of a cough. They basically phone us because they want us to check 51 52 them over” (P12) 53 54 Paramedics were sympathetic to these views, and admitted to their own internal conflicts 55 when taking people into hospital, which they felt may not be in the best interest of their 56 57 patients. A clear narrative for this dilemma was described by P15 who was unable to safely 58 59 60
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1 2 3 leave the patient at home, but knowing he had a cough and was to be admitted to a COVID 4 5 ward BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 “When I took the gentleman in who was off his legs to the COVID ward, I was talking to the 8 9 nurse there and I said I felt like I was deciding almost his fate, which wasn’t very nice. (P15) 10 11 Paramedic participants raised occupational and pay related issues including the importance of 12 protecting their income whilst acknowledging their fortunate position in comparison to others 13 14 in society at this time. 15 16 “I am alive and I have a job which is more than what most people have got at the moment. I 17 18 have food and I’m notFor worried peer about bills” review (P10) only 19 20 Additional overtime incentives were initiated by their employer, and whist views were mixed, 21 paramedic 10 told of her fear in taking on overtime: 22 23 24 “I have no intention of doing overtime……Less is more with me I think, it’s like Russian 25 roulette isn’t it, you know the bullet is in the barrel and you will spin it because you have to 26 go to work, but then I wouldn’t go and put two or three more bullets in the gun and spin it to 27 take that chance” (P10) 28 29 All participants except one had access to the recommended Personnel Protective Equipment 30 31 (PPE), but they also reported frustrations on how PPE guidance had changed as the pandemic 32 evolved and experienced variation in approaches to PPE across organisations other home 33 34 nations. 35 36 “there seems to be substantial differences between what Public Health England and Wales 37 http://bmjopen.bmj.com/ 38 are throwing out in regards to what the World Health Organisation and the Resus Council 39 are throwing out” (P06) 40 41 Concerns were reported over their training and the quality of PPE, and all except two felt it 42 was not designed for ambulance service use. Paramedic 14 shared his thoughts on the quality 43 44 of equipment and reported his concerns around using out of date PPE:
45 on October 1, 2021 by guest. Protected copyright. 46 “we are using masks now with stickers with 2012 on and I know that we are only using them 47 48 because we can’t get any of the newer masks, and that is not what you want to hear…you 49 want to know what you are wearing is safe to do your job”. (P14) 50 51 Nine of the participants reported that their wellbeing and mental health had been negatively 52 impacted on by the pandemic. They talked about their collective anxieties around COVID-19, 53 54 and the effect the ever-presence of the virus in their practice. Paramedic 9 said: 55 56 “as a station we were definitely a little on edge. Cleaning door handles in the station, going 57 58 round starting my shift, cleaning any touchable things I could think of, kettles, taps anything 59 like that and that is not me… it’s turned me into a bit OCD about it. It’s definately affected 60 my mental health” (P09)
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1 2 3 Paramedics talked about the difficulties they felt in providing care in emergencies due to 4 5 COVID-19, and how this resulted in frustrations and tension in them. BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 “one night, unfortunately, I had 3 cardiac arrests, which was tough and unfortunately the 8 9 guy I was working with needed the versa flow hood, so I was on my own...that was really 10 really hard going on your own… everything about it felt wrong and it was such hard work 11 and it was frustrating”. (P12) 12 13 Only one participant reported having accessed wellbeing or mental health support promoted 14 or provided by their employer, and this was a routine call from the wellbeing team with 15 16 support which they declined. Participants did however reflect on the increased focus and 17 18 provision of supportFor for mental peer health within review ambulance services only in recent years. 19 20 “I think the mental health side of it is 100 times better than what it was, I don’t think we had 21 anything before” (P14) 22 23 Despite this, participants either did not feel they needed such support or accessed this from 24 25 other sources such as their family, friends, colleagues, private counsellors, the service 26 27 Chaplain or information publically available. Following the national lockdown our 28 29 participants described the importance of exercise, being outdoors and in nature for their 30 wellbeing during the pandemic, along with the need for time to recover between duties. They 31 32 told how the pandemic had resulted in them doing more activities with their families and had 33 34 re-kindled interest in activities such as walking and cycling. Paramedic 10 shared how during 35 lockdown, the one hour a day out walking was so important and: 36
37 http://bmjopen.bmj.com/ 38 “But I have started back cycling, that was one of things I was allowed to do, so the bike has been 39 covered with a blanket in the garage for months, and because you were allowed to cycle and pretty 40 much nothing else, I started again.”- (P19) 41 42 Categories 2. Rapid disruption and adaptation 43 44 All participants faced rapid disruption to their personal and working lives. This included
45 on October 1, 2021 by guest. Protected copyright. 46 issues such as adhering to the lockdown rules, social distancing, holiday cancelations and 47 difficulties visiting family. This rapid disruption subsequently required rapid adaptation. 48 49 50 “when you find yourself in a situation whereby the world is a completely different place so 51 quickly you have to adapt, you have to” (P7) 52 53 They told of the need adapt, learn and assimilate new information quickly. This included 54 55 clinical information around the COVID-19 virus, clinical guidance, and ways of working in 56 PPE. Paramedic 12 shared how it could be overwhelming: 57 58 59 60
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1 2 3 “you have been thrown information constantly, there’s updates after updates after updates, 4 5 things are changing near enough I wouldn’t say hourly but frequently changing. Yes you are BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 probably being suitably informed but it is overwhelming” (P12) 7 8 All of the paramedics reported the rapid change in encountering patients reluctant to accept 9 care, and how they faced difficult clinical and ethical decisions in their practice which had 10 11 become far more challenging due to the context of the pandemic. 12 13 14 “I would say at least about 50% are refusing to go in…. so you are really having to convince 15 and weigh up the balance of fighting against that, because if you do take them in and they do 16 catch it and they do die, its weighing up the responsibility of that aswell” (P05) 17 18 “I spent nearly an hourFor and peera half trying reviewto convince the familyonly that the risk factors were 19 significant enough that actually going to the A&E and so did the doctor … 2 and a half hours 20 later we did manage to gain consent to wilfully go to hospital” –P07 21 22 Paramedics also said people were presenting much sicker due to delaying care for fear of 23 contracting COVID-19 as expressed by P07: 24 25 26 “People are really poorly out there because they are leaving it too late” (P07) 27 28 All of the paramedics faced changes to clinical practice and guidance and whilst there were 29 30 mixed views, for some, information felt rushed. 31 32 “I feel they were pushed out too quickly without adequate training and understanding from 33 frontline crews, and I fear this will lead to risky decisions being made that would not 34 otherwise benefit the patients” (P11) 35 36 There was also a suggestion that during the pandemic, a more pragmatic approach was being
37 http://bmjopen.bmj.com/ 38 taken to clinical practice guidelines and the quality of care was being compromised. Some 39 paramedics expressed concerns about their professional registration. 40 41 “The HCPC [Health & Care Professions Council] came out early on and said they will make 42 allowances, they will consider the coronavirus if our decision making is called into question” 43 (P18) 44
45 The pandemic was thought to have expedited many changes in clinical practice including end on October 1, 2021 by guest. Protected copyright. 46 47 of life care. Powerful accounts were shared of managing patients at the end of life during the 48 49 pandemic which avoided delays and hospital admission, which gave them satisfaction. 50 Paramedic 18 however told of his discomfort over end of life care treatment packs, telling 51 52 how he and his colleagues were: 53 54 55 “Uncomfortable about it because they have just been put on trucks with very little training on 56 it (P18) 57 58 Paramedics in our study said how their interaction pre-pandemic with people with mental health 59 issues was often tactile, involving holding hands and using nonverbal communication. 60
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1 2 3 Participants explained how the pandemic had significantly changed this. 4 5 “the human side of our job feels like it has been taken away, and its really put into sharp BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 contrast how much humanity we usually have in our job … personally I have found it really 7 difficult leaving relatives behind and especially when you have got time critical, possibly not 8 going to survive patients. We had a lady with a very dense CVA the other day, GCS 3, 82 9 10 year old, and had to leave her daughter standing crying on the side of the road.” – P03 11 And 12 13 “Before you would go in and have chats or banter with them its lost all that, first thing you 14 do is put a mask on them, it can’t be nice for the family coming in with all this stuff on, and I 15 16 think its lost a lot of that relationship between the paramedic and the patient (P14) 17 18 For peer review only 19 All of the participants except one reported a rapid rise in the use of technology in their 20 personal and working lives such as video conferencing and mobile phone apps. 21 22 23 “I speak to my children on a daily basis by phone or group video, which is something else we 24 have got into the habit of doing now. We will get into a group call which we have never done 25 before” (P13) 26 27 They also shared the positive impact of the pandemic on use of such technology across the 28 29 wider healthcare system: 30 “The NHS in regard to medical advances has been very fearful in moving forward, particularly with 31 32 video conferencing and now seeing GPs using Zoom, which is amazing” (P07) 33 Categories 3: Trust in communication and information 34 35 All of our participants accessed information from a wide range of sources, and told how trust 36
37 in information sources was essential. For some, there was general confusion on what sources http://bmjopen.bmj.com/ 38 39 could be trusted? 40 41 “I don’t know who to trust with it”(P12) 42 43 There were mixed views on information provided by the Government; for some there was 44
45 distrust in their motives, and a feeling information was being politicised with the government on October 1, 2021 by guest. Protected copyright. 46 47 being careful to protect themselves. 48 49 “Because they [the Government] have done that to protect themselves and not us as 50 healthcare workers… the thing is, you don’t really know from what you’re seeing how true 51 everything is. (P12) 52 53 Eleven of the paramedics felt suitably informed by their employer, and provided rich 54 55 accounts of the many platforms and mediums that were used in this process. 56 57 “excellent policy of daily updates and ZOOM meeting to ensure all staff were aware of the 58 latest updates” (P01) 59 60
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1 2 3 They did however report how the constant negative reporting of COVID-19 was having an 4 5 impact on the kinds of presentations they were encountering in their clinical practice: BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 “Those people were saying they were watching the news 24 hours a day, all the media 8 9 reports, googling things they didn’t know about and getting themselves into a point they end 10 up calling us through stress. So very bizarre times”. (P16) 11 12 All participants told of the danger of information overload for them and the public. They also 13 believed social media could be negative and positive. Positive accounts included its role in 14 15 communicating with colleagues, friends and family and the Facebook group provided by their 16 17 employer. Some however did not use social media and avoided it to protect their mental 18 health. Media reportsFor providing peer daily updates review and reporting only the challenges they faced were a 19 20 constant reminder of their job and were not welcomed and created anxieties and difficulties 21 22 with loved ones. 23 24 “I try not to watch the news, and I mean I had it on constantly, and I realised it was having 25 26 an effect on my daughters mental health” (P10) 27 During the early stages of the pandemic, many frontline staff including paramedics took to 28 29 social media posting pictures and videos of themselves which ranged from messages of 30 31 protecting the NHS to highly choreographed dances in theatre scrubs, PPE, nursing and 32 33 clinical uniforms. Paramedic 10 said: 34 35 “I don’t think it is right that we are posing in masks, and I mean the medical professional as 36 a whole, dancing up and down the corridors meters away, potentially from ITU where people 37 are fighting for their lives… you wouldn’t get a crematorium bloke doing a song and dance in http://bmjopen.bmj.com/ 38 a crematorium would you?” (P10) 39 40 Categories 4: United in hardship 41 42 Despite the significant challenges and fear, Paramedics reported a sense of solidarity across their 43 44 profession and organisation in being united working together to tackling the pandemic.
45 on October 1, 2021 by guest. Protected copyright. 46 “I think generally people come together in a crisis normally and I think it’s taken this to make WAST 47 and other services a lot nicer place to work for. Because we are all up against it though aren’t we, we 48 are in it together” (P10) 49 50 They also told of the positive aspects of the COVID-19 pandemic on the communities within which 51 they lived and worked and recognised that the visible public support such as gifts and clapping was 52 53 nice, but some felt somewhat embarrassed 54 55 “It’s really nice to get to know that you are supported, it is emotional, but I do get somewhat 56 embarrassed by it, because we are out there doing a job and decisions we make are informed 57 decisions. (P13) 58 59 60
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1 2 3 During the pandemic there was a very visible campaign in the media of NHS Heroes. 4 5 This narrative was promoted within society by charities, media and government. Despite this, BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 all of the participants except one did not consider themselves to be ‘Heroes’ but rather, felt 8 they were just doing their job. 9 10 11 “What is the definition of a hero?... I go to work every day, and I know if I caught it I know 12 my dad would call me a hero, I know my daughter would be beside herself but eventually she 13 would probably think of me as a hero, but yeah I would be a liar if I didn’t say there were 14 times I think of myself as a hero, but ultimately I am a human being who is scared” (P10) 15 16 The heroic definition of paramedic 10 was equally reflected in the accounts of the other 17 18 paramedic participants,For who peerall felt a professional review responsibility only to society to provide care 19 20 during a pandemic but would not choose to be exposed to such risk if they had a choice and 21 shared a sense of melancholy that if they weren’t doing this, who would be? 22 23 24 “We have lost colleagues, and if this virus wasn’t here they would be around now, and that 25 isn’t what you expect when you become a paramedic I don’t think. I never expected a global 26 pandemic which could kill us to happen” (P15) 27 28 The outpouring of public support for paramedics within the NHS did however reveal tensions 29 30 in their relationship with some members of society. Paramedics told how some in society 31 32 were blasé, not observing social distancing rules, and the Victory in Europe (VE) day 33 celebrations were cited as examples. It was suggested by paramedics that when COVID-19 34 35 was over, they would be forgotten about by the public and return to long hospital delays, 36
37 inappropriate use of ambulances and violence and aggression directed towards them http://bmjopen.bmj.com/ 38 39 “once it’s over they will forget about us again and it will be back to abusing people again 40 and sitting around in hospitals and where has this been until now when you needed us? (P14) 41 42 Basic Social Process (BSP): Tragic choices 43 44 The BSP in paramedic experiences of providing care during the 2020 COVID-19 pandemic
45 on October 1, 2021 by guest. Protected copyright. 46 was recognised to involve Tragic Choices. We draw on the work of Calabresil and Bobbitt 47 48 (1978)[23] who explored how societies allocate tragically scarce resources and make such 49 50 "tragic choices".This perspective considers the various methods for allocating and dispensing 51 goods and services with paramedics during a pandemic, which includes resources such as 52 53 equipment, labour, knowledge and information, care and services. The BSP reflects life's 54 55 pricelessness and Calabresi and Bobbitt’s [23] discussions on such pricing of the invaluable 56 57 and the cost of costing, which we argue occurs when ordinary activities and resources 58 become increasingly scarce and tragic in a pandemic. 59 60
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1 2 3 Calabresi and Bobbitt [23] highlight that price does not place a value on goods or 4 5 activities but permits comparisons, such as the cost of investing in healthcare, preparing for BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 pandemics, PPE, and pay and can be compared in price with building safer roads etc. Neither 8 of these prices places a value on life, but when compared can illuminate the cost, for example 9 10 of how many lives may be saved by building safer roads rather than spending on building 11 12 new hospitals for instance? Ignoring the informative worth of price, costs and the value we 13 14 assign to issues revealed in this study on paramedic care in pandemics may risk losing more 15 lives in this and future pandemics and paradoxically undermine life’s pricelessness? 16 17 18 An Evolved GroundedFor Theory peer Tragic choicesreview in providing only paramedic care during the 19 2020 COVID-19 Pandemic: 20 21 A grounded theory (GT) was constructed of the Tragic choices faced by Paramedics in 22 23 providing care during the 2020 COVID-19 Pandemic. Exploration of the tragic choices that 24 such pandemics necessitate reveals the variety of processes by which these choices are made 25 26 across the thematic categories presented above, and outlined in the GT (fig 1) which includes 27 28 the BSP of Tragic choices at its centre, influenced by Personal & professional tragic choices, 29 30 Organisational tragic choices and Societal tragic choices. 31 32 Tragic personal & professional choices: 33 34 Challenging personal and professional choices were experienced by paramedics in our study 35 36 around protecting themselves, their families and their duty to provide care during the
37 pandemic. Whilst the public considered them heroes, Paramedics did not consider themselves http://bmjopen.bmj.com/ 38 39 within this characterisation. Many definitions of heroism to society exist, but key factors 40 41 include: the voluntary nature, risk of harm, acting for benefit of others and without 42 expectation of gain. [24-26] Our paramedics were indeed acting in the benefit of others, but 43 44 reported feeling scared and it was a job they were paid for. [27] found similar self-
45 on October 1, 2021 by guest. Protected copyright. 46 deprecatory accounts from paramedics of such heroic status and so acceptance of such hero 47 48 characterization is complex. 49 50 Tragic professional choices were revealed in clinical practice; especially with PPE, included 51 52 its dehumanizing impact, frustrations over quality, and variation in guidance across 53 organizations. Such disparity in guidelines have also been reported in the literature 28]. They 54 55 faced rapid changes in their role in provision of end of life care (EOL), which some were not 56 57 confident in, and whilst studies have previously reported [29-33], empowering staff at the 58 59 point of delivery of EoLC has been deemed crucial and can make a real life impact [30]. The 60
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1 2 3 pandemic may have expedited developments in paramedic provision of EoLC and tragic 4 5 decisions may have been made? However, powerful positive EoLC encounters were reported BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 by paramedics which may reflect professional and organisational growth which can emerge 8 from such crisis [34-35] 9 10 11 Tensions were revealed with clinical decisions, balancing risks and benefits of managing 12 13 patients at home. These decisions may again involve tragic choices and moral compromises 14 which HCW’s are often confronted and can have far-reaching consequences when searching 15 16 for the best treatment option [36-37] contend that often policy makers are removed from the 17 18 devastating heartbreak,For sorrow, peer and guilt reviewof personal tragic only choices and consequently, the 19 moral burden of legitimacy and responsibility falls not just on the tragic choice itself, but also 20 21 on how the tragic choice is made? Paramedics in our study reflected on the cost of isolation 22 23 measures and anxiety in patients; many of whom were elderly and experiencing increased 24 25 loneliness. Such feelings of loneliness, and anxiety during the pandemic have been reported 26 elsewhere [38], with the elderly and those with chronic conditions said to be paying the 27 28 highest price due to increased age and disease related risks [39,40] 29 30 31 Ethical and professional issues revealed around the paramedic-patient relationship, have been 32 revealed in other studies [41-44], and have potential to result in moral injury, which is the 33 34 psychological distress that results from actions, or the lack of them, which violate someone’s 35 36 moral or ethical code [45]. Powerful accounts of tragic choices may also reinforce public
37 drama, with reports in the media of paramedics constantly second-guessing themselves as to http://bmjopen.bmj.com/ 38 39 whether people needed to go to hospital, and choices that may “make a patient better or kill 40 41 them” [46]. Family members, friends and the wider public received daily reminders of their 42 43 role, and risks they faced, and paramedics in our study told how they could not escape these 44 reminders when off duty.
45 on October 1, 2021 by guest. Protected copyright. 46 47 The tragic professional and personal choices being made by paramedics in our study were 48 also reported during the COVID-19 pandemic [47], who similarly reported situations of 49 50 challenging decisions, balancing physical and mental healthcare needs with those of patients, 51 52 aligning their duty to patients with those to family and friends, and providing care with 53 54 constrained resources. They reported feelings of fear, anxiety, and reported tragic choices 55 they made in seeking support, which rarely involved their employer, but rather family, friends 56 57 and close colleagues. The positive impact of exercise and being in nature was reported, and 58 59 60
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1 2 3 many studies have identified the positive relationship between nature and good mental health 4 5 and well-being [48-51] BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 Moral injury can however have benefits, as those individuals and organisations who have 8 9 endured such experiences during crisis have experienced post-traumatic growth [34]. Indeed, 10 11 reported such professional growth and increased awareness in paramedics following their 12 13 experiences with patients who died by suicide, but this relied on supportive cultures, training 14 and preparation to overcome the negative emotional impact [35]. Once again, tragic and 15 16 costly choices may be required to invest resources and mental energies in these issues. 17 18 Tragic organisationalFor choices: peer review only 19 20 21 Our study revealed the influence of many choices made by the paramedics employing 22 23 organisation. For organizations, crisis such as pandemics are strategically challenging, and 24 the associated disruption of demand, capacity, increased uncertainty and financial instability 25 26 forces a reassessment of business operations [52,53]. Ambulance services are in the front line 27 28 response to the pandemic, and whilst preparations are made for pandemics, we found they 29 can also stimulate innovation and cooperation. Whilst rapid changes may have resulted in 30 31 confusion and anxiety in areas of clinical practice and PPE, many positive issues emerged. 32 33 These included the provision of clinical support, better information and communication, 34 35 professional growth, digitalization and many more. It could be argued such accelerated 36 innovation and growth was forced rather than discretionary, to ensure the organization’s
37 http://bmjopen.bmj.com/ 38 survival and was because it had to [54] 39 40 Paramedics in our study reported the importance of trustworthy communication in their 41 42 personal and professional lives during the pandemic, which has also been reported in 43 44 previous pandemics, [12,55,56] They also reported challenges of information overload, how
45 on October 1, 2021 by guest. Protected copyright. 46 social media could be positive and negative and how some avoided it. Tragic choices are 47 therefore again made around communication, where the content and medium of such 48 49 communication may be positive, but may also add to public drama, confusion and the tragic 50 51 context. 52 53 The study revealed many positive cultural and organisational issues, such as increased unity 54 55 which has been reported during other pandemics [43, 57]. One such visibly example of this 56 57 spirit of solidarity and unity was WAST’s ‘Reach for the Razor’ campaign [58], where staff 58 were encouraged to shave facial hair (light-heartedly) to prevent the limitations of facemask 59 60
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1 2 3 fit when hair is present. Organisations and staff, may therefore have choice in being in united 4 5 in pandemics, but such unity may involve longer partnerships? BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 Increased problems with mental health and wellbeing were reported by participants, which 8 9 are also reflected in literature [59-62] found HCW’s during pandemics exposed to virus are 10 11 1.7 times more likely to develop psychological distress and PTSD compared to non-exposed 12 13 workers. Few participants sought support in our study which is also reported in the literature 14 [63]. Despite this, there is a lack of evidence based interventions staff working in such high 15 16 risk occupational roles [64] National Institute for Health and Care Excellence 2018[65], 17 18 which has promptedFor urgent callspeer for research review to be prioritised only in this area [66]. Paramedics 19 participants also reported incentives for working overtime during the pandemic, but many 20 21 recognised the need for time off to recover; indeed working such overtime is associated with 22 23 anxiety, depression and burn out [67-69]). Paramedics and employing organisations 24 25 therefore face tragic choices when balancing service delivery during a pandemic with 26 potential for increasing mental health problems and access to evidence based interventions. 27 28 29 Paramedics in our study felt we were not prepared for the pandemic and appeared to accept 30 31 the unique situation, yet preparations were made and experiences of previous pandemics 32 reported in the literature. Billing et al [70] (2020) conducted a meta-synthesis of healthcare 33 34 workers’ experiences of working on the frontline and views about support during COVID-19 35 36 and comparable pandemics.[70] The results of this study were remarkably resonant with the
37 themes within the present study and others EMS studies[29], [71] Issues faced in the COVID- http://bmjopen.bmj.com/ 38 39 19 pandemic were not totally unprecedented and questions therefore emerge around tragic 40 41 choices around leaning lessons from previous, current and future pandemics on the role and 42 43 synthesis research literature. 44
45 Tragic societal choices: on October 1, 2021 by guest. Protected copyright. 46 47 Paramedics on the visible campaign of public support for the National Health Services (NHS) 48 49 through the media, politicians and Thursday night clapping and gifts. This context has echoes 50 51 of Calabresil and Bobbitt’s (1978)[23] notion that what counts as a tragic choice is in many 52 53 ways a matter of public drama. Such public drama may have been influenced by campaigns 54 such as the 'Stay Home, Protect the NHS, Save Lives' Protect the NHS slogan reinforced 55 56 through daily briefings, reports of increasing hospital bed capacity, deaths by COVID-19 and 57 58 frontline workers being unable to access PPE. Calabresil and Bobbitt (1978)[23] argue that 59 when public drama in this way is central to designating tragic goods, society treats them as 60
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1 2 3 tragic when in fact, they need not have been tragically scarce, and devise an alternative 4 5 allocation scheme to distribute it. Many of the choices and goods during usual times involve BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 clinical and policy decision based on a range of factors such as clinical and cost effectiveness. 8 Given warnings over the inevitability of a pandemic questions emerge from a public policy 9 10 perspective around the role and influence of such public drama in decision making? As heart- 11 12 warming as they are, such outpouring of public appreciating may misdirect attention from 13 14 fundamental issues around our planning and resourcing of the current and future responses to 15 pandemics, and indeed may be making these goods and services actually become more tragic 16 17 in nature? We argue there may however be more choice inherent in the allocation and 18 For peer review only 19 distribution of these issues, tragic as they may be, which led to the turning ordinarily scarce 20 21 resources into a tragically scarce ones and again relate to value and the cost of costing. 22 23 Participants had been able to access the recommended PPE, but they also reported concerns 24 25 over its quality, which have also been raised by other HCW’s ,[72,73] Societies and 26 governments globally have faced problems with PPE supply chains, as prior to the pandemic, 27 28 China produced half the world’s face masks, and as COVID-19 spread across China their 29 30 exports stopped [74]. This is a vulnerability to society reflects how this ordinary resource 31 32 quickly became tragically scarce and subject to much public drama. Pandemic preparations 33 no doubt saved lives, but some suggest this response was neither been well prepared nor 34 35 adequate [75,76]). point to unheeded warnings over lack of preparation, including limited 36
37 numbers of intensive care beds and PPE which were revealed at a time of austerity when bed http://bmjopen.bmj.com/ 38 numbers were being cut, which again highlights the tragic choices being made and potential 39 40 subsequent costs. 41 42 43 The high profile campaigns above along with and directing people to 111 as the first point of 44 call, may have proved effective given increases in 111 calls and reductions in ambulance use
45 on October 1, 2021 by guest. Protected copyright. 46 of up to 16% [77,78] at a time when ambulance services have been experiencing record 47 48 levels of demand and yearly increases of around 5%,[79,80]. Despite this, paramedics talked 49 of patients avoiding care for fear of contracting COVID-19, which again has echoes of tragic 50 51 choices, as [81]suggest that the 'Stay Home, Protect the NHS, Save Lives' slogan was indeed 52 53 too successful, and may have dissuaded people from going to hospital to treat other urgent 54 55 conditions. Evidence is also emerging on such avoidance of emergency care and reciprocal 56 increases in Out of Hospital Cardiac Arrests unrelated to COVID-19, along with stroke 57 58 patients arriving too late to receive vital clot busting drugs [82] 59 60
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1 2 3 Paramedics predicted they would be forgotten about by the public after the pandemic and 4 5 return to long hospital delays, inappropriate ambulance use and violence and aggression. BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 Such a situation unfolded during the VE day celebrations, with reports of NHS staff having 8 been stabbed in the back, with street parties and increases in intoxicated and violence patients 9 10 assaulting staff [83,84] These issues clearly threaten the notion of being ‘united in hardship’ 11 12 and questions emerge around the relationship between healthcare workers duty of care owed 13 14 to protect society during a pandemic and societies reciprocal obligations to protect them. This 15 flipside of self-sacrifice and martyrism was also played out as tragic drama with questions 16 17 emerging of trust and how society and governments will reward and pay for its healthcare? 18 For peer review only 19 [85,86] 20 21 OECD (2020)[87] found that 43.4% of NHS workers work up to five hours unpaid overtime 22 23 per week, while 3.5 % reported working more than 11 hours of unpaid per week. Huge 24 25 variations were also found in investment in healthcare, with the UK investing £3,257 per 26 capita (9.8% of GDP), which is 18th of all OECD countries, despite being the fifth largest 27 28 economy globally. This again highlights how governments and society cannot ignore the 29 30 informative value of price, costs and the value we assign to paramedic care in pandemics. 31 32 Every aspect from procurement of pandemic preparation and PPE to paramedic wellbeing 33 may be informed by the price we are prepared to pay, how we value health services and the 34 35 subsequent costs involved. Societies and governments will continue to make tragic choices in 36
37 this and future pandemics in order to protect un-priceable lives. http://bmjopen.bmj.com/ 38 39 Strengths and limitations 40 41 The study involved a small sample and was conducted in one ambulance service. The sample 42 43 size is however consistent with other qualitative studies using this methodology. Remarkable 44 consistency and agreement was found throughout analysis, member checking and previous 45 on October 1, 2021 by guest. Protected copyright. 46 studies which adds to the trustworthiness and transferability of our findings. Non-response 47 48 bias may have occurred as participants may be more proactive, and likely to engage in 49 50 research. Using the VoIP of Skype™ was deemed a strength, despite technical difficulties 51 and one corrupted recording. The research team included insider researchers with three 52 53 practicing paramedics and whilst this may be considered a potential bias, we stated up front 54 55 the constructivist nature of evolved grounded theory and how the background of these 56 57 researchers added to the richness of the GT. We also made extensive reflective notes, cross 58 validated coding and analysis and conducted member checking with a very good response 59 60 rate and heterogeneity in responses.
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1 2 3 We were unable to involve patients and public in the study due to the speed of developments. 4 5 We do however plan to disseminate the results to study participants and patient organisations BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 8 9 10 11 12 13 14 Conclusion 15 16 The COVID-19 pandemic is the biggest challenge in modern times to have faced providers of 17 18 healthcare globally.For Paramedics peer are at the review forefront of the UKonly pandemic response, and this 19 study has revealed rich insights on their experiences. A wide range of issues faced by 20 21 paramedics were revealed through the categories presented. We suggest that the BSP in 22 23 paramedic experiences of providing care during the 2020 COVID-19 pandemic involves 24 Tragic Choices. We synthesized the emergent categories with the work of Calabresil and 25 26 Bobbitt (1978)[23] and the BSP and developed a new theoretical context through the 27 28 constructed GT of ‘Tragic Choices paramedic experiences of providing care during the 2020 29 30 COVID-19 pandemic’ which included: Tragic Personal & professional choices, ‘Tragic 31 organisational choices and ‘Tragic societal Choices’. This GT richly articulates the range of 32 33 issues faced by paramedics in terms costs endured, prices paid and the value we assign to 34 35 these issues and the tragic nature of these choices. 36 The epidemiological and virological battle continues to analyse and understand the 37 http://bmjopen.bmj.com/ 38 causes, effects and treatments for COVID-19 and other viruses. We do not yet know how 39 40 effective these efforts will be, but it may be an ever-present struggle which continues to face 41 42 humanity? Despite this, the catastrophic societal, professional, personal and organisational 43 impact of such pandemics may be considered to be somewhat more predictable. The social 44
45 sciences qualitative methodology used in this study revealed rich insights into paramedic care on October 1, 2021 by guest. Protected copyright. 46 47 during the COVID-19 pandemic and the categories and tragic choices revealed are 48 49 remarkably similar to those experienced by other HCW’s, paramedics in this and previous 50 pandemics across the world. It is therefore a disturbing, but undeniable reality that providing 51 52 paramedic care during the COVID 19 2020 pandemic involved no-win situations, but rather 53 54 they all have their particular advantages and tragic flaws. A wide range of tragic choices 55 56 therefore have to be made and subsequent costs borne, where in a world of competing and 57 conflicting decisions and resources the pricelessness of life is a mere sentiment and 58 59 unhelpful. Tragic Choices have to be made and implicit prices must be placed on lives saved. 60
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1 2 3 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 Contributors: NR Led on preparing the manuscript. LS, CH and JW collaborated on the 7 design, data collection and analysis, and all approved the final manuscript. 8 9 Funding: This work was supported by WAST Pathway to Portfolio Funding 10 11 Competing interests: NR, CH and LS are employees of WAST 12 13 Disclaimer: The views and opinions expressed therein are those of the authors and do not 14 necessarily reflect those of WAST 15 16 Data availability statement: Data are available from the authors on request 17 18 Acknowledgments:For The authors peer would likereview to thank all of only the paramedic who participated in 19 this study and WAST for sponsoring 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 References 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 1. Coronavirus Disease (COVID-19) Situation Reports [Internet]. Who.int. 2020 [cited 7 8 13 January 2021]. Available from: https://www.who.int/emergencies/diseases/novel- 9 coronavirus-2019/situation-reports 10 11 2. Coronavirus disease (COVID-19) – World Health Organization [Internet]. Who.int. 12 13 2020 [cited 13 January 2021]. Available from: 14 15 https://www.who.int/emergencies/diseases/novel-coronavirus-2019 16 3. UK G. Number of coronavirus (COVID-19) cases and risk in the UK. online: 17 18 https://www.For gov. uk/guidance/coronavirus-covid-19-information-for-the-public. peer review only 19 20 2020a 21 4. UK G. Coronavirus (COVID-19) action plan [Internet]. GOV.UK. 2020b [cited 13 22 23 January 2021]. Available from: 24 25 https://www.gov.uk/government/publications/coronavirus-action-plan 26 27 5. Davies, K. Higginson, R. (2005) Evolution and healthcare impact of a 21st Century 28 avian flu pandemic. British Journal of Nursing. Vol 14, No 20 29 30 6. Juszczyk J (2004) Global strategies in prevention of infectious diseases on the turn of 31 32 the second and third millennium: expectation versus reality. Przegl Epidemiol 33 34 58(Suppl 1): 5–9 (in Polish) 35 7. Thompson AK, Faith K, Gibson JL, Upshur RE. Pandemic influenza preparedness: an 36
37 ethical framework to guide decision-making. BMC medical ethics. 2006 Dec http://bmjopen.bmj.com/ 38 39 1;7(1):12. 40 8. Chua SE, Cheung V, Cheung C, McAlonan GM, Wong JW, Cheung EP, Chan MT, 41 42 Wong MM, Tang SW, Choy KM, Wong MK. Psychological effects of the SARS 43 44 outbreak in Hong Kong on high-risk health care workers. The Canadian Journal of
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Paramedic Experiences of providing Care in Wales (UK) during the 2020 COVID-19 Pandemic (PECC-19): A qualitative study using Evolved Grounded Theory
ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2021-048677.R1
Article Type: Original research
Date Submitted by the 12-Apr-2021 Author:
Complete List of Authors: Rees, Nigel; Welsh National Ambulance Service NHS Trust, Pre-Hospital Emergency Research Unit Smythe, Lauren; Welsh National Ambulance Service NHS Trust, Pre- Hospital Emergency Research Unit Hogan, Chloe; Welsh National Ambulance Service NHS Trust, Pre- Hospital Emergency Research Unit Williams, Julia; University of Hertfordshire, School of Health and Social Work
Primary Subject Emergency medicine Heading: http://bmjopen.bmj.com/ Emergency medicine, Health policy, Health services research, Secondary Subject Heading: Epidemiology, Evidence based practice
COVID-19, ACCIDENT & EMERGENCY MEDICINE, Organisation of health Keywords: services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT
on October 1, 2021 by guest. Protected copyright.
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1 2 3 Paramedic Experiences of providing Care in Wales (UK) during the 4 5 2020 COVID-19 Pandemic (PECC-19): BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 A qualitative study using Evolved Grounded Theory 8 9 *Nigel Rees, PhD1. Lauren Smythe MSc1. Chloe Hogan MSc1 Julia Williams PhD2 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 1. Pre Hospital Emergency Research Unit (PERU), Welsh Ambulance Services NHS Trust (WAST), 36 Institute of Life Sciences, Swansea University, Swansea, Wales, 37 http://bmjopen.bmj.com/ 38 2. Paramedic Clinical Research Unit (ParaCRU), University of Hertfordshire, Hatfield, 39 Hertfordshire, United Kingdom 40 41 42 43 44
45 on October 1, 2021 by guest. Protected copyright. 46 47 48 *Corresponding author: email [email protected] 49 50 51 52 53 54 55 56 57 58 59 60
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1 2 3 Abstract 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 Objective To explore Paramedic experiences of providing care during the 2020 COVID-19 7 8 pandemic and develop theory in order to inform future policy and practice. 9 10 Design Qualitative study using Constructivist Evolved Grounded Theory (EGT) 11 12 methodology. One-to-one semi-structured interviews were conducted using a general 13 14 interview guide. Voice over Internet Protocol (VoIP) was used through Skype™. 15 16 Setting Conducted between March 2020 and November 2020 in the Welsh Ambulance 17 18 Services NHS TrustFor UK which peer serves a populationreview of three only million. 19 20 Participants Paramedics were recruited through a poster circulated by email and social 21 22 media. Following purposive sampling, twenty Paramedics were enrolled and interviewed. 23 24 Results Emergent categories included: Protect me to protect you, Rapid disruption and 25 26 adaptation, Trust in communication and information and United in hardship. The Basic 27 28 Social Process was recognised to involve Tragic Choices, conceptualised through an EGT 29 including Tragic personal & professional choices including concerns over PPE, protecting 30 31 themselves and their families, impact on mental health and difficult clinical decisions, Tragic 32 33 organisational choices including decision making support, communication, mental health and 34 35 wellbeing and Tragic societal choices involving public shows of support, utilisation and 36 resourcing of health services.
37 http://bmjopen.bmj.com/ 38 39 Conclusions 40 41 Rich insights were revealed into paramedic care during the COVID-19 pandemic consistent 42 43 with other research. This care was provided in the context of competing and conflicting 44 decisions and resources, where Tragic Choices have to be made which may challenge life’s
45 on October 1, 2021 by guest. Protected copyright. 46 pricelessness. Wellbeing support, clinical decision making, appropriate PPE and healthcare 47 48 resourcing are all influenced by choices made before and during the pandemic, and will 49 50 continue as we recover and plan for future pandemics. The impact of COVID-19 may persist, 51 especially if we fail to learn, if not we risk losing more lives in this and future pandemics and 52 53 threatening the overwhelming collective effort which united society in hardship when 54 55 responding to the COVID-19 Pandemic. 56 57 Registration Integrated Research Application System [IRAS ID: 282623]. 58 59 60
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1 2 3 Strengths and limitations of this study: 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 The study was set up rapidly in one UK ambulance service very early in their 7 8 response to COVID-19. This was a unique opportunity to capture experiences of 9 Paramedics providing care as the pandemic unfolded. 10 11 A rich Evolved Grounded Theory has been constructed on the tragic choices in 12 13 providing paramedic care during the 2020 COVID-19 Pandemic, but is limited by 14 15 being conducted in one ambulance service. 16 Remarkable consistency and agreement was found throughout analysis, member 17 18 checking andFor previous peer studies which review adds to the trustworthiness only and transferability of 19 20 our findings. 21 Using the VoIP of Skype™ was deemed a strength, especially in the context of a 22 23 pandemic due to social distancing. Technical difficulties did occur, and one recording 24 25 became corrupted. 26 27 The research team included insider researchers with three practicing paramedics and 28 whilst this may be considered a potential bias, we stated up front the constructivist 29 30 nature of evolved grounded theory and how the background of these researchers 31 32 added to the richness of the GT. 33 34 35 36
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1 2 3 Background 4 5 The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) the virus responsible BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 for COVID-19 was first reported in December, 2019 in China [1]. COVID-19 rapidly spread 8 across the world, qualifying as a global pandemic by the World Health Organization (WHO 9 10 2020) on March 11 2020 affected 220 countries, areas or territories, with 54 558 120 11 th 12 confirmed cases and 1 320 148 deaths as of 11 Nov 2020 [2]. In the UK plans prepared in 13 the aftermath of the 2009 H1N1 global threat were enacted [3], which included the response 14 15 from ambulance and wider health services and also wider societal measures including 16 17 isolation methods, closing schools, businesses and self-isolation [4] 18 For peer review only 19 Prior to the COVID-19 pandemic, calls were repeatedly made for Health Care 20 21 Workers (HCWs) in the UK to ready themselves for such pandemics [5, 6] which may 22 23 involve difficult and ethical challenging decisions shaped by the local context and cultural 24 values [7]. HCW’s face personal challenges and fears related to unemployment, isolation, 25 26 contracting disease, mortality, and infecting family [8-12]. The COVID-19 pandemic 27 28 presented a unique opportunity to understand these issues from a UK paramedic perspective, 29 30 and a program of research was developed by our team to explore Paramedic Experiences of 31 providing Care during the 2020 COVID-19 Pandemic (PECC-19). We conducted an initial 32 33 review of the literature which found a paucity of published research concerning paramedics 34 35 along with many of the challenges reported above [13]. The present paper reports the finding 36 of a qualitative study we conducted which aimed to explore Paramedic experiences of 37 http://bmjopen.bmj.com/ 38 providing care during the 2020 COVID-19 pandemic and develop theory in order to inform 39 40 future policy and practice. 41 42 Methodology 43 44 Strauss & Corbin’s (1998) [14] evolved form of GT methodology was used, which
45 on October 1, 2021 by guest. Protected copyright. 46 follows a constructivist perspective and accepts that people construct the realities in which 47 48 they participate and thus highlights the researcher–participant dyad and the co-construction of 49 50 data [15]. In Evolved GT, the researcher is a “passionate participant as facilitator of multi- 51 voice reconstruction” (Lincoln & Guba 2005 p. 196) [16]. Three researchers within this study 52 53 were practicing paramedics and provided (limited) frontline care during the 2020 COVID-19 54 55 pandemic which in turn facilitated insight, awareness and ability to bring meaning to the data 56 [17]. Such background does though have the potential for preconceived ideas and previous 57 58 encounters to influence the construction of the evolved GT, and to counteract this, member 59 60 checking and reflexivity methods were employed.
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1 2 3 Setting and sampling: 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 The study was conducted between March 2020 and November 2020 in the Welsh Ambulance 7 Services NHS Trust (WAST) UK which serves a population of three million. Participants 8 9 were recruited through a poster circulated through email and social media. Information packs 10 11 were sent to participants containing a consent form to sign and return to the researcher; 12 confirmed verbally during interview. Participants were selected using purposive sampling 13 14 based on the characteristics of gender, age, experience, and educational development to 15 16 reflect the paramedic workforce. Confidentiality and anonymity was assured. 17 18 Methods For peer review only 19 20 21 Data Collection 22 23 Interviews 24 25 One hour, one-to-one semi-structured interviews were conducted using a general interview 26 guide (supplementary file). The internet carriage service Skype™ was used, which is a Voice 27 28 over Internet Protocol VoIP (VoIP) [18]. VoIP was beneficial in the COVID-19 pandemic 29 30 context as paramedics are a scattered workforce, practicing social distancing during the study 31 32 and this approach minimised time needed away from clinical duties to participate. Interviews 33 were video recorded with memos taken, transcribed verbatim and checked for accuracy 34 35 against the recordings. 36
37 Patient and Public Involvement: http://bmjopen.bmj.com/ 38 39 40 As this study was rapidly set up and due to the context of WAST responding to COVID-19 41 42 we did not involve patients or members of the public. We do however intend to present our 43 findings to public and patient groups. 44
45 on October 1, 2021 by guest. Protected copyright. 46 Data analysis 47 48 Analysis followed Strauss and Corbin’s (1998) [14] three levels of open, axial and selective 49 50 coding entered into NIVO 12 software to create a coding book. Open coding compared data 51 for similarities, differences and questions regarding emergent phenomena resulting in 52 53 identification of indicators; words or phrases of interest. Indicators were subsumed under 54 55 higher level headings known as concepts, which stand for the emerging phenomena. Axial 56 coding involved subsuming concepts into higher-level headings known as categories. 57 58 Selective coding also involved “explication of the story line” (Strauss & Corbin 1998, p. 148) 59 60 [14] which involves identifying the Basic Social Process (BSP) at work, around which all
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1 2 3 other categories revolve. The BSP meaningfully and easily relates to all other categories and 4 5 should have clear and grabbing qualities [19] upon which to theoretical construct the Evolved BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 Grounded Theory (GT) through weaving all of the fractured data back together and 8 conceptualising the relationship among these three levels of coding. A second researcher 9 10 [CH] independently reviewed this coding. Participant’s also member-checked data analysis 11 12 by reviewing excerpts from the coding book and returning comments on evolving theory. 13 14 Reflective notes were made by researchers considering theory development and monitoring 15 the researchers’ influences on this process. 16 17 18 Ethical considerationsFor peer review only 19 20 The study was submitted to the Integrated Research Application System [IRAS ID: 282623]. 21 22 NHS Research Ethical review was not required within Health Research Authority guidance 23 [20], but issues of an ethical nature remained which were observed by following the 24 25 Economic and Social Research Council [21] framework. Participants provided verbal and 26 27 written consent. All data were collected and stored in accordance with GDPR (2018) [22] 28 29 regulations. We recognised staff may become emotionally upset during the research, and a 30 range of support was made available. 31 32 33 Results 34 35 Twenty six paramedics responded to the poster call, six did not end up participating and a 36 final sample of twenty were consented and enrolled into the study. One paramedic was not 37 http://bmjopen.bmj.com/ 38 interviewed due to purposive sampling and one of the interview recordings became corrupted 39 40 and not included in the analysis. Table 1. Includes characteristics about the sample of 41 42 paramedic participants. 43 44
45 Paramedic on October 1, 2021 by guest. Protected copyright. 46 EMS Self educational 47 Participant Gender Experience Age range Isolated development Interviewed 48 P01 Male >10 26-45 No Traditional training PILOT 1 - 09/04/2020 49 P02 Female 3 to 10 46-55 Yes Higher Education PILOT 2 - 09/04/2020 50 51 P03 Female >10 46-55 Yes Traditional training Interview 3- 16/04/2020 52 P04 Male >10 26-45 No Higher Education Interview 4 - 20/04/2020 53 P05 Female 1 to 3 26-45 yes Higher Education Interview 6 - 20/04/2020 54 P06 Female >10 46-55 No Higher Education Not Sampled 55 P07 Female 3 to 10 26-45 Yes Higher Education Interview 5 -20/04/2020 56 P08 Male 3 to 10 26-45 Yes Higher Education Interview 7 -23/04/2020 57 P09 Male 1 to 3 19-26 No Higher Education Interview 16 - 21/05/2020 58 59 P10 Female >10 26-45 No Higher Education Interview 10 - 30/04/2020 60 P11 Female >10 26-45 Yes Higher Education Interview 8 - 28/04/2020
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1 2 3 P12 Male >10 26-45 No Traditional training Interview 9 - 29/04/2020 4 P13 Female 3 to 10 26-45 Yes Higher Education Interview 15 - 20/05/2020 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 5 6 P14 Male >10 46-55 Yes Traditional training Interview 14 - 19/05/2020 7 P15 Female 1 to 3 26-45 Yes Higher Education Interview 12 - 05/05/2020 8 P16 Male >10 56-60 No Higher Education Interview 13 - 07/05/2020 9 P17 Male 1 to 3 Incomplete No Higher Education Interview 11 - 04/05/2020 10 P18 Male 3 to 10 26-45 Yes Higher Education Interview 17 - 27/05/2020 11 P19 Male 3 to 10 26-45 Yes Incomplete Interview 18 - 03/06/2020 12 13 P20 Male >10 46-55 Yes Traditional training Interview 19 - 02/07/2020 14 Table 1 Sample of paramedic participants 15 16 The following four categories emerged: Protect me to protect you, Rapid disruption and 17 adaptation, Trust in communication and information, United in hardship. The BSP in 18 For peer review only 19 paramedic experiences of providing care during the 2020 COVID-19 pandemic was 20 21 recognised to involve Tragic Choices and was conceptualised in the GT in fig 1 which 22 23 involved Tragic personal & professional choices, Tragic organisational choices and Tragic 24 societal choices: 25 26 27 Fig 1. Grounded Theory (GT): Tragic choices in providing paramedic care during the 2020 28 COVID-19 Pandemic 29 30 Category 1. Protect me to protect you 31 All of our paramedic participants except one expressed concern for themselves and 32 33 their families during the pandemic due to a perception of the risks their occupation posed: 34 35 “Not so much catching it myself, but bringing it home to my family” (P09) 36
37 http://bmjopen.bmj.com/ 38 They were concerned of risks to family members with underlying health issues, revealing 39 40 internal conflict between their occupational role and the safety of their families. A wide range 41 of underlying conditions were reported including pregnancy, asthma, immunosuppression 42 43 [HIV negative] and leukaemia, and participants often mentioned concern for family members 44
45 from these vulnerable groups and their elderly relatives. on October 1, 2021 by guest. Protected copyright. 46 “my partner works as a frontline carer, he is immunosuppressed but is HIV negative”… “he 47 48 has got significant risks, but obviously with me working in the frontline, and him in frontline 49 as well, one of the early fears were do we basically separate or do I basically separate from 50 him to reduce that risk. Whilst I would always do my job, I would never forgive myself if I 51 thought for one moment that I had brought something from the community and brought it 52 back home” (P08) 53 54 Paramedics told how practicing in this context was unlike anything they had experienced 55 56 before, with an ever-present sense of fear and risk. 57 58 “I felt anxious going to work, I felt scared going to work, it’s scary to think you can go to 59 work and bring it home, that is not a nice feeling” (P12) 60
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1 2 3 All participants talked about front line HCW’s dying from COVID-19, and in April 2020, a 4 5 paramedic within the study area died from COVID-19. From this point on all of the BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 participants reflected on the death of their colleague, as shared by paramedic 14: 8 9 “We have [name] working here… its knocked it a bit closer to home again,….it’s had a 10 massive effect because he was such a big character” (P14) 11 12 Powerful accounts were relayed of their sustained exposure and close proximity to patients 13 14 with COVID-19 symptoms. Paramedic 15 who contracted COVID 19 along with her partner 15 16 early in the pandemic, said prior to contracting COVID-19 she: 17 18 “was petrified really,For standing peer in a house review where someone isonly coughing and spluttering for half 19 an hour, 45minutes and then conveying them to hospital, which took another hour…..you are 20 21 in the back of the vehicle 2 meters by 1 meter… with a patient who is coughing virus into the 22 air potentially and I’m breathing that air in. so it was horrible really. (P15) 23 24 They reported attempts being made to mitigate the risks of working in this environment, 25 which involved changes in practice and provision of PPE. Such efforts however did little to 26 27 alleviate this fear-filled context, which seemed to influence their morale. Paramedic 15 was: 28 29 30 “really worried because I knew the masks didn’t fit me properly, so I was anxious and I felt a 31 bit demotivated to be in work, that I didn’t want to be there because every day I was going in 32 and it was a permanent risk really” (P15) 33 34 Paramedics in our study reported this environment of fear influenced many areas of their 35 36 lives, including changes to hygiene practices such as changing out of their uniform and
37 showering in work, avoiding visiting friends and relatives, and talking more openly on http://bmjopen.bmj.com/ 38 39 making preparations for their own death. They also reported a dramatic reduction in workload 40 41 and that people were avoiding care for fear of contracting COVID-19 which they felt was 42 43 influenced by the media and conversely increased emergency calls to assess people who 44 thought they had COVID-19.
45 on October 1, 2021 by guest. Protected copyright. 46 47 “There was a lot of fear among patients, which I can understand. You see a lot of death and 48 fearmongering on the news, there was a lot of fear among patients. But then that also led to 49 frustration amongst us on the road because we are going to patients who are phoning 999 50 because they have a bit of a cough. They basically phone us because they want us to check 51 52 them over” (P12) 53 54 Paramedics were sympathetic to these views, and admitted to their own internal conflicts 55 when taking people into hospital, which they felt may not be in the best interest of their 56 57 patients. A clear narrative for this dilemma was described by P15 who was unable to safely 58 59 60
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1 2 3 leave the patient at home, but knowing he had a cough and was to be admitted to a COVID 4 5 ward BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 “When I took the gentleman in who was off his legs to the COVID ward, I was talking to the 8 9 nurse there and I said I felt like I was deciding almost his fate, which wasn’t very nice. (P15) 10 11 Paramedic participants raised occupational and pay related issues including the importance of 12 protecting their income whilst acknowledging their fortunate position in comparison to others 13 14 in society at this time. 15 16 “I am alive and I have a job which is more than what most people have got at the moment. I 17 18 have food and I’m notFor worried peer about bills” review (P10) only 19 20 Additional overtime incentives were initiated by their employer, and whist views were mixed, 21 paramedic 10 told of her fear in taking on overtime: 22 23 24 “I have no intention of doing overtime……Less is more with me I think, it’s like Russian 25 roulette isn’t it, you know the bullet is in the barrel and you will spin it because you have to 26 go to work, but then I wouldn’t go and put two or three more bullets in the gun and spin it to 27 take that chance” (P10) 28 29 All participants except one had access to the recommended Personnel Protective Equipment 30 31 (PPE), but they also reported frustrations on how PPE guidance had changed as the pandemic 32 evolved and experienced variation in approaches to PPE across organisations other home 33 34 nations. 35 36 “there seems to be substantial differences between what Public Health England and Wales 37 http://bmjopen.bmj.com/ 38 are throwing out in regards to what the World Health Organisation and the Resus Council 39 are throwing out” (P06) 40 41 Concerns were reported over their training and the quality of PPE, and all except two felt it 42 was not designed for ambulance service use. Paramedic 14 shared his thoughts on the quality 43 44 of equipment and reported his concerns around using out of date PPE:
45 on October 1, 2021 by guest. Protected copyright. 46 “we are using masks now with stickers with 2012 on and I know that we are only using them 47 48 because we can’t get any of the newer masks, and that is not what you want to hear…you 49 want to know what you are wearing is safe to do your job”. (P14) 50 51 Nine of the participants reported that their wellbeing and mental health had been negatively 52 impacted on by the pandemic. They talked about their collective anxieties around COVID-19, 53 54 and the effect the ever-presence of the virus in their practice. Paramedic 9 said: 55 56 “as a station we were definitely a little on edge. Cleaning door handles in the station, going 57 58 round starting my shift, cleaning any touchable things I could think of, kettles, taps anything 59 like that and that is not me… it’s turned me into a bit OCD about it. It’s definitely affected my 60 mental health” (P09)
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1 2 3 Paramedics talked about the difficulties they felt in providing care in emergencies due to 4 5 COVID-19, and how this resulted in frustrations and tension in them. BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 “one night, unfortunately, I had 3 cardiac arrests, which was tough and unfortunately the 8 9 guy I was working with needed the versa flow hood, so I was on my own...that was really 10 really hard going on your own… everything about it felt wrong and it was such hard work 11 and it was frustrating”. (P12) 12 13 Only one participant reported having accessed wellbeing or mental health support promoted 14 or provided by their employer, and this was a routine call from the wellbeing team with 15 16 support which they declined. Participants did however reflect on the increased focus and 17 18 provision of supportFor for mental peer health within review ambulance services only in recent years. 19 20 “I think the mental health side of it is 100 times better than what it was, I don’t think we had 21 anything before” (P14) 22 23 Despite this, participants either did not feel they needed such support or accessed this from 24 25 other sources such as their family, friends, colleagues, private counsellors, the service 26 27 Chaplain or information publically available. Following the national lockdown our 28 29 participants described the importance of exercise, being outdoors and in nature for their 30 wellbeing during the pandemic, along with the need for time to recover between duties. They 31 32 told how the pandemic had resulted in them doing more activities with their families and had 33 34 re-kindled interest in activities such as walking and cycling. Paramedic 10 shared how during 35 lockdown, the one hour a day out walking was so important and: 36
37 http://bmjopen.bmj.com/ 38 “But I have started back cycling, that was one of things I was allowed to do, so the bike has 39 been covered with a blanket in the garage for months, and because you were allowed to cycle 40 and pretty much nothing else, I started again.” (P19) 41 42 Categories 2. Rapid disruption and adaptation 43 44 All participants faced rapid disruption to their personal and working lives. This included
45 on October 1, 2021 by guest. Protected copyright. 46 issues such as adhering to the lockdown rules, social distancing, holiday cancelations and 47 48 difficulties visiting family. This rapid disruption subsequently required rapid adaptation. 49 50 “when you find yourself in a situation whereby the world is a completely different place so 51 quickly you have to adapt, you have to” (P7) 52 53 They told of the need adapt, learn and assimilate new information quickly. This included 54 55 clinical information around the COVID-19 virus, clinical guidance, and ways of working in 56 57 PPE. Paramedic 12 shared how it could be overwhelming: 58 59 60
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1 2 3 “you have been thrown information constantly, there’s updates after updates after updates, 4 5 things are changing near enough I wouldn’t say hourly but frequently changing. Yes you are BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 probably being suitably informed but it is overwhelming” (P12) 7 8 All of the paramedics reported the rapid change in encountering patients reluctant to accept 9 care, and how they faced difficult clinical and ethical decisions in their practice which had 10 11 become far more challenging due to the context of the pandemic. 12 13 14 “I would say at least about 50% are refusing to go in…. so you are really having to convince 15 and weigh up the balance of fighting against that, because if you do take them in and they do 16 catch it and they do die, its weighing up the responsibility of that as well” (P05) 17 18 And For peer review only 19 “I spent nearly an hour and a half trying to convince the family that the risk factors were 20 21 significant enough that actually going to the A&E and so did the doctor … 2 and a half hours 22 later we did manage to gain consent to wilfully go to hospital” (P07) 23 24 Paramedics also said people were presenting much sicker due to delaying care for fear of 25 contracting COVID-19 as expressed by P07: 26 27 28 “People are really poorly out there because they are leaving it too late” (P07) 29 30 All of the paramedics faced changes to clinical practice and guidance and whilst there were 31 mixed views, for some, information felt rushed. 32 33 34 “I feel they were pushed out too quickly without adequate training and understanding from 35 frontline crews, and I fear this will lead to risky decisions being made that would not 36 otherwise benefit the patients” (P11)
37 http://bmjopen.bmj.com/ 38 There was also a suggestion that during the pandemic, a more pragmatic approach was being 39 40 taken to clinical practice guidelines and the quality of care was being compromised. Some 41 paramedics expressed concerns about their professional registration. 42 43 “The HCPC [Health & Care Professions Council] came out early on and said they will make 44 allowances, they will consider the coronavirus if our decision making is called into question” 45 (P18) on October 1, 2021 by guest. Protected copyright. 46 47 The pandemic was thought to have expedited many changes in clinical practice including end 48 49 of life care. Powerful accounts were shared of managing patients at the end of life during the 50 51 pandemic which avoided delays and hospital admission, which gave them satisfaction. 52 Paramedic 18 however told of his discomfort over end of life care treatment packs, telling 53 54 how he and his colleagues were: 55 56 “Uncomfortable about it because they have just been put on trucks with very little training on 57 58 it (P18) 59 Paramedics in our study said how their interaction pre-pandemic with people with mental health 60
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1 2 3 issues was often tactile, involving holding hands and using nonverbal communication. 4 5 Participants explained how the pandemic had significantly changed this. BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 “the human side of our job feels like it has been taken away, and its really put into sharp 8 contrast how much humanity we usually have in our job … personally I have found it really 9 difficult leaving relatives behind and especially when you have got time critical, possibly not 10 going to survive patients. We had a lady with a very dense CVA the other day…and had to 11 leave her daughter standing crying on the side of the road.” (P03) 12 13 And 14 15 “Before you would go in and have chats or banter with them its lost all that, first thing you 16 do is put a mask on them, it can’t be nice for the family coming in with all this stuff on, and I 17 think its lost a lot of that relationship between the paramedic and the patient (P14) 18 For peer review only 19 20 All of the participants except one reported a rapid rise in the use of technology in their 21 22 personal and working lives such as video conferencing and mobile phone apps. 23 24 “I speak to my children on a daily basis by phone or group video, which is something else we 25 26 have got into the habit of doing now. We will get into a group call which we have never done 27 before” (P13) 28 29 They also shared the positive impact of the pandemic on use of such technology across the 30 wider healthcare system: 31 32 “The NHS in regard to medical advances has been very fearful in moving forward, 33 particularly with video conferencing and now seeing GPs using Zoom, which is amazing” 34 35 (P07) 36 Categories 3: Trust in communication and information 37 http://bmjopen.bmj.com/ 38 All of our participants accessed information from a wide range of sources, and told how trust 39 40 in information sources was essential. For some, there was general confusion on what sources 41 42 could be trusted: 43 44 “I don’t know who to trust with it” (P12)
45 on October 1, 2021 by guest. Protected copyright. 46 There were mixed views on information provided by the Government; for some there was 47 48 distrust in their motives, and a feeling information was being politicised with the government 49 50 being careful to protect themselves. 51 52 “Because they [the Government] have done that to protect themselves and not us as 53 healthcare workers… the thing is, you don’t really know from what you’re seeing how true 54 everything is. (P12) 55 56 Eleven of the paramedics felt suitably informed by their employer, and provided rich 57 58 accounts of the many platforms and mediums that were used in this process. 59 60
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1 2 3 “excellent policy of daily updates and ZOOM meeting to ensure all staff were aware of the 4 latest updates” (P01) BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 5 6 They did however report how the constant negative reporting of COVID-19 was having an 7 8 impact on the kinds of presentations they were encountering in their clinical practice: 9 10 “Those people were saying they were watching the news 24 hours a day, all the media 11 12 reports, googling things they didn’t know about and getting themselves into a point they end 13 up calling us through stress. So very bizarre times”. (P16) 14 All participants told of the danger of information overload for them and the public. They also 15 16 believed social media could be negative and positive. Positive accounts included its role in 17 18 communicating withFor colleagues, peer friends andreview family and the only Facebook group provided by their 19 20 employer. Some however did not use social media and avoided it to protect their mental 21 health. Media reports providing daily updates and reporting the challenges they faced were a 22 23 constant reminder of their job and were not welcomed and created anxieties and difficulties 24 25 with loved ones. 26 27 “I try not to watch the news, and I mean I had it on constantly, and I realised it was having 28 an effect on my daughters mental health” (P10) 29 30 During the early stages of the pandemic, many frontline staff including paramedics took to 31 32 social media posting pictures and videos of themselves which ranged from messages of 33 34 protecting the NHS to highly choreographed dances in theatre scrubs, PPE, nursing and 35 36 clinical uniforms. Paramedic 10 said:
37 http://bmjopen.bmj.com/ 38 “I don’t think it is right that we are posing in masks, and I mean the medical professional as 39 a whole, dancing up and down the corridors meters away, potentially from ITU where people 40 are fighting for their lives… you wouldn’t get a crematorium bloke doing a song and dance in 41 a crematorium would you” (P10) 42 43 Categories 4: United in hardship 44
45 Despite the significant challenges and fear, Paramedics reported a sense of solidarity across their on October 1, 2021 by guest. Protected copyright. 46 47 profession and organisation in being united working together to tackling the pandemic. 48 49 “I think generally people come together in a crisis normally and I think it’s taken this to make WAST 50 and other services a lot nicer place to work for. Because we are all up against it though aren’t we, we 51 are in it together” (P10) 52 53 They also told of the positive aspects of the COVID-19 pandemic on the communities within which 54 they lived and worked and recognised that the visible public support such as gifts and clapping was 55 56 nice, but some felt somewhat embarrassed 57 58 59 60
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1 2 3 “It’s really nice to get to know that you are supported, it is emotional, but I do get somewhat 4
embarrassed by it, because we are out there doing a job and decisions we make are informed BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 5 6 decisions. (P13) 7 During the pandemic there was a very visible campaign in the media of NHS Heroes. 8 9 This narrative was promoted within society by charities, media and government. Despite this, 10 11 all of the participants except one did not consider themselves to be ‘Heroes’ but rather, felt 12 they were just doing their job. 13 14 15 “What is the definition of a hero?... I go to work every day, and I know if I caught it I know 16 my dad would call me a hero, I know my daughter would be beside herself but eventually she 17 would probably think of me as a hero, but yeah I would be a liar if I didn’t say there were 18 times I think of myselfFor as a hero, peer but ultimately review I am a human only being who is scared” (P10) 19 20 The heroic definition of paramedic 10 was equally reflected in the accounts of the other 21 22 paramedic participants, who all felt a professional responsibility to society to provide care 23 24 during a pandemic but would not choose to be exposed to such risk if they had a choice and 25 shared a sense of melancholy that if they weren’t doing this, who would be? 26 27 28 “We have lost colleagues, and if this virus wasn’t here they would be around now, and that 29 isn’t what you expect when you become a paramedic I don’t think. I never expected a global 30 pandemic which could kill us to happen” (P15) 31 32 The outpouring of public support for paramedics within the NHS did however reveal tensions 33 34 in their relationship with some members of society. Paramedics told how some in society 35 36 were blasé, not observing social distancing rules, and the Victory in Europe (VE) day
37 celebrations were cited as examples. It was suggested by paramedics that when COVID-19 http://bmjopen.bmj.com/ 38 39 was over, they would be forgotten about by the public and return to long hospital delays, 40 41 inappropriate use of ambulances and violence and aggression directed towards them 42 43 “once it’s over they will forget about us again and it will be back to abusing people again 44 and sitting around in hospitals and where has this been until now when you needed us” (P14)
45 on October 1, 2021 by guest. Protected copyright. 46 Basic Social Process (BSP): Tragic choices 47 48 The BSP in paramedic experiences of providing care during the 2020 COVID-19 pandemic 49 50 was recognised to involve Tragic Choices. We draw on the work of Calabresil and Bobbitt 51 52 (1978) [23] who explored how societies allocate tragically scarce resources and make such 53 54 "tragic choices". This perspective considers the various methods for allocating and 55 dispensing goods and services with paramedics during a pandemic, which includes resources 56 57 such as equipment, labour, knowledge and information, care and services. The BSP reflects 58 59 life's pricelessness and Calabresi and Bobbitt’s [23] discussions on such pricing of the 60
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1 2 3 invaluable and the cost of costing, which we argue occurs when ordinary activities and 4 5 resources become increasingly scarce and tragic in a pandemic. BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 Calabresi and Bobbitt [23] highlight that price does not place a value on goods or 8 9 activities, but rather, it permits comparisons, such as the cost of investing in healthcare, 10 11 preparing for pandemics, PPE and pay, all of which can be compared in price with other 12 13 activities such as building safer roads for instance. These prices do not however place a value 14 on life, but when compared, they can illuminate the cost; for example of how many lives may 15 16 be saved by building safer roads rather than spending on building new hospitals for instance. 17 18 The informative worthFor of price, peer costs and review the value we assign only to issues revealed in this study 19 on paramedic care cannot therefore be ignored, or otherwise in pandemics risk losing more 20 21 lives in this and future pandemics and paradoxically undermine life’s pricelessness. 22 23 24 An Evolved Grounded Theory Tragic choices in providing paramedic care during the 25 2020 COVID-19 Pandemic: 26 27 A grounded theory (GT) was constructed of the Tragic choices faced by Paramedics in 28 providing care during the 2020 COVID-19 Pandemic. Exploration of the tragic choices that 29 30 such pandemics necessitate reveals the variety of processes by which these choices are made 31 32 across the thematic categories presented above, and outlined in the GT (fig 1) which includes 33 34 the BSP of Tragic choices at its centre, influenced by Personal & professional tragic choices, 35 Organisational tragic choices and Societal tragic choices. 36
37 http://bmjopen.bmj.com/ 38 Tragic personal & professional choices: 39 40 Challenging personal and professional choices were experienced by paramedics in our study 41 around protecting themselves, their families and their duty to provide care during the 42 43 pandemic. Whilst the public considered them heroes, Paramedics did not consider themselves 44
45 within this characterisation. Many definitions of heroism to society exist, but key factors on October 1, 2021 by guest. Protected copyright. 46 47 include: the voluntary nature, risk of harm, acting for benefit of others and without 48 expectation of gain [24-26]. Our paramedics were indeed acting in the benefit of others, but 49 50 reported feeling scared and it was a job they were paid for. Tangherlini (2000) [27] found 51 52 similar self-deprecatory accounts from paramedics of such heroic status and so acceptance of 53 such hero characterization is complex. 54 55 56 Tragic professional choices were revealed in clinical practice; especially with PPE, included 57 58 its dehumanizing impact, frustrations over quality, and variation in guidance across 59 organizations. Such disparity in guidelines have also been reported in the literature [28]. They 60
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1 2 3 faced rapid changes in their role in provision of End of Life Care (EoLC), which some were 4 5 not confident in, and whilst studies have previously reported this [29-33], empowering staff BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 at the point of delivery of EoLC has been deemed crucial and can make a real life impact 8 [30]. The pandemic may have expedited developments in paramedic provision of EoLC and 9 10 tragic decisions may have been made. However, powerful positive EoLC encounters were 11 12 reported by paramedics which may reflect professional and organisational growth which can 13 14 emerge from such crises [34-35]. 15 16 Tensions were revealed with clinical decisions, balancing risks and benefits of managing 17 18 patients at home. TheseFor decisions peer may again review involve tragic only choices and moral compromises 19 which HCW’s are often confronted and can have far-reaching consequences when searching 20 21 for the best treatment option [36-37] contend that often policy makers are removed from the 22 23 devastating heartbreak, sorrow, and guilt of personal tragic choices and consequently, the 24 25 moral burden of legitimacy and responsibility falls not just on the tragic choice itself, but also 26 on how the tragic choice is made. Paramedics in our study reflected on the cost of isolation 27 28 measures and anxiety in patients; many of whom were elderly and experiencing increased 29 30 loneliness. Such feelings of loneliness, and anxiety during the pandemic have been reported 31 32 elsewhere [38], with the elderly and those with chronic conditions said to be paying the 33 highest price due to increased age and disease related risks [39,40]. 34 35 36 Ethical and professional issues revealed around the paramedic-patient relationship, have been
37 revealed in other studies [41-44], and have potential to result in moral injury, which is the http://bmjopen.bmj.com/ 38 39 psychological distress that results from actions, or the lack of them, which violate someone’s 40 41 moral or ethical code [45]. Powerful accounts of tragic choices may also reinforce public 42 43 drama, with reports in the media of paramedics constantly second-guessing themselves as to 44 whether people needed to go to hospital, and choices that may “make a patient better or kill
45 on October 1, 2021 by guest. Protected copyright. 46 them” [46]. Family members, friends and the wider public received daily reminders of their 47 48 role, and risks they faced, and paramedics in our study told how they could not escape these 49 reminders when off duty. 50 51 52 The tragic professional and personal choices being made by paramedics in our study were 53 54 also reported during the COVID-19 pandemic [47], who similarly reported situations of 55 challenging decisions, balancing physical and mental healthcare needs with those of patients, 56 57 aligning their duty to patients with those to family and friends, and providing care with 58 59 constrained resources. They reported feelings of fear, anxiety, and reported tragic choices 60
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1 2 3 they made in seeking support, which rarely involved their employer, but rather family, friends 4 5 and close colleagues. The positive impact of exercise and being in nature was reported, and BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 many studies have identified the positive relationship between nature and good mental health 8 and well-being [48-51]. 9 10 11 Moral injury can however have benefits, as those individuals and organisations who have 12 13 endured such experiences during crises have experienced post-traumatic growth [34]. Indeed, 14 reported such professional growth and increased awareness in paramedics following their 15 16 experiences with patients who died by suicide, but this relied on supportive cultures, training 17 18 and preparation to overcomeFor peer the negative review emotional impact only [35]. Once again, tragic and 19 costly choices may be required to invest resources and mental energies in these issues. 20 21 22 Tragic organisational choices: 23 24 Our study richly revealed the influence of many choices made by the paramedics employing 25 26 organisation. The COVID-19 is undoubtedly the most significant crises to have been faced by 27 28 health care organisations and ambulance services internationally in modern times, yet societal 29 crises can be strategically challenging to organisations outside of the pandemic context, and 30 31 the associated disruption of demand, capacity, increased uncertainty and financial instability 32 33 forces a reassessment of business operations [52, 53]. Ambulance services are in the front 34 35 line response to the pandemic, and whilst preparations are made for such pandemics, the 36 employing ambulance service were forced to learn, react and adapt as the pandemic unfolded.
37 http://bmjopen.bmj.com/ 38 Whilst rapid changes may have resulted in confusion and anxiety in areas of clinical practice 39 40 and PPE, many positive issues emerged where the pandemic context appears to have 41 42 stimulated a significant amount of innovation and cooperation. For instance, the organisation 43 initiated more provision of clinical support, better information, communication and 44
45 digitalization, factors which may have created an environment for improved professional on October 1, 2021 by guest. Protected copyright. 46 47 growth. It should be recognised that such accelerated innovation and growth was forced 48 rather than discretionary, which can occur to ensure the organization’s survival and because it 49 50 had to [54]. Limited assumptions can therefore be made if such innovation could be sustained 51 52 outside of a pandemic context. 53 54 Paramedics in our study reported the importance of trustworthy communication in their 55 56 personal and professional lives during the pandemic, which has also been reported in 57 58 previous pandemics, [12, 55, 56] They also reported challenges of information overload, how 59 social media could be positive and negative and how some avoided it. Tragic choices are 60
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1 2 3 therefore again made around communication, where the content and medium of such 4 5 communication may be positive, but may also add to public drama, confusion and the tragic BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 context. 8 9 The study revealed many positive cultural and organisational issues, such as increased unity 10 11 which has been reported during other pandemics [43, 57]. One such visible example of this 12 13 spirit of solidarity and unity was WAST’s ‘Reach for the Razor’ campaign [58], where staff 14 were encouraged to shave facial hair (light-heartedly) to prevent the limitations of facemask 15 16 fit when hair is present. Organisations and staff, may therefore have choice in being in united 17 18 in pandemics, but suchFor unity peer may involve review longer partnerships. only 19 20 Increased problems with mental health and wellbeing were reported by participants, which 21 22 are also reflected in literature [59-62] found HCW’s during pandemics exposed to virus are 23 24 1.7 times more likely to develop psychological distress and PTSD compared to non-exposed 25 workers. Few participants sought support in our study which is also reported in the literature 26 27 [63]. Despite this, there is a lack of evidence based interventions staff working in such high 28 29 risk occupational roles [64, 65], which has prompted urgent calls for research to be prioritised 30 31 in this area [66]. Paramedic participants also reported incentives for working overtime during 32 the pandemic, but many recognised the need for time off to recover; indeed working such 33 34 overtime is associated with anxiety, depression and burn out [67-69]. Paramedics and 35 36 employing organisations therefore face tragic choices when balancing service delivery during
37 a pandemic with potential for increasing mental health problems and access to evidence http://bmjopen.bmj.com/ 38 39 based interventions. 40 41 42 Paramedics in our study felt we were not prepared for the pandemic and appeared to accept 43 the unique situation, yet preparations were made and experiences of previous pandemics 44
45 reported in the literature. Billings et al (2020) [70] conducted a meta-synthesis of healthcare on October 1, 2021 by guest. Protected copyright. 46 47 workers’ experiences of working on the frontline and views about support during COVID-19 48 and comparable pandemics. The results of this study were remarkably resonant with the 49 50 themes within the present study and others EMS studies [29, 71]. Issues faced in the COVID- 51 52 19 pandemic were therefore not totally unprecedented and questions therefore emerge around 53 54 tragic choices, learning lessons from previous, current and future pandemics, and the role and 55 synthesis of research literature. 56 57 58 Tragic societal choices: 59 60
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1 2 3 Paramedics and other HCW’s were celebrated by visible campaigns of public support for the 4 5 National Health Services (NHS) through the media, politicians and Thursday night clapping BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 and gifts. This context has echoes of Calabresil and Bobbitt’s (1978) [23] notion that what 8 counts as a tragic choice is in many ways a matter of public drama. Such public drama may 9 10 have been influenced by campaigns such as the 'Stay Home, Protect the NHS, Save Lives' 11 12 Protect the NHS’ slogan reinforced through daily briefings, reports of increasing hospital bed 13 14 capacity, deaths by COVID-19 and frontline workers being unable to access PPE. Calabresil 15 and Bobbitt (1978) [23] argue that when public drama in this way is central to designating 16 17 tragic goods, society treats them as tragic when in fact, they need not have been tragically 18 For peer review only 19 scarce, and devise an alternative allocation scheme to distribute it. Many of the choices and 20 21 goods during usual times involve policy decision based on a range of factors such as clinical 22 and cost effectiveness. Given warnings over the inevitability of a pandemic, questions 23 24 therefore emerge from a public policy perspective around the role and influence of such 25 26 public drama in decision making. As heart-warming as they are, such outpouring of public 27 appreciating may misdirect attention from fundamental issues around our planning and 28 29 resourcing of the current and future responses to pandemics, and indeed may be making these 30 31 goods and services actually become more tragic in nature. We argue there may however be 32 33 more choice inherent in the allocation and distribution of these issues, tragic as they may be, 34 which led to the turning ordinarily scarce resources into a tragically scarce ones and again 35 36 relate to value and the cost of costing.
37 http://bmjopen.bmj.com/ 38 Participants had been able to access the recommended PPE, but they also reported concerns 39 40 over its quality, which have also been raised by other HCW’s, [72,73] Societies and 41 42 governments globally have faced problems with PPE supply chains, as prior to the pandemic, 43 44 China produced half the world’s face masks, and as COVID-19 spread across China their
45 exports stopped [74]. This is a vulnerability to society reflects how this ordinary resource on October 1, 2021 by guest. Protected copyright. 46 47 quickly became tragically scarce and subject to much public drama. Pandemic preparations 48 49 no doubt saved lives, but some suggest this response was neither been well prepared nor 50 51 adequate [75, 76], and point to unheeded warnings over lack of preparation, including limited 52 numbers of intensive care beds and PPE which were revealed at a time of austerity when bed 53 54 numbers were being cut, which again highlights the tragic choices being made and potential 55 56 subsequent costs [76]. 57 58 The high profile campaigns above along with and directing people to 111 as the first point of 59 60 call, may have proved effective given increases in 111 calls and reductions in ambulance use
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1 2 3 of up to 16% [77,78] at a time when ambulance services have been experiencing record 4 5 levels of demand and yearly increases of around 5%, [79,80]. Despite this, paramedics talked BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 of patients avoiding care for fear of contracting COVID-19, which again has echoes of tragic 8 choices, as Hope et al (2020) [81] suggest that the 'Stay Home, Protect the NHS, Save Lives' 9 10 slogan was indeed too successful, and may have dissuaded people from going to hospital to 11 12 treat other urgent conditions. Evidence is also emerging on such avoidance of emergency care 13 14 and reciprocal increases in Out of Hospital Cardiac Arrests unrelated to COVID-19, along 15 with stroke patients arriving too late to receive vital clot busting drugs [82]. 16 17 18 Paramedics predictedFor they would peer be forgotten review about by the only public after the pandemic and 19 return to long hospital delays, inappropriate ambulance use and violence and aggression. 20 21 Such a situation unfolded during the Victory in Europe (VE) day celebrations, with reports of 22 23 NHS staff having been stabbed in the back, with street parties and increases in intoxicated 24 25 and violence patients assaulting staff [83, 84]. These issues clearly threaten the notion of 26 being ‘United in Hardship’ and questions emerge around the relationship between healthcare 27 28 workers duty of care owed to protect society during a pandemic and societies reciprocal 29 30 obligations to protect them. Self-sacrifice and martyrism of health workers played out as 31 32 tragic public drama forces us therefore to confront such issues of trust and how society and 33 governments reward and pay for its healthcare system and its workers [85, 86]? 34 35 36 The Organisation for Economic Co-operation and Development (OECD 2020) [87] found
37 that 43.4% of NHS workers work up to five hours unpaid overtime per week, while 3.5 % http://bmjopen.bmj.com/ 38 39 reported working more than 11 hours of unpaid per week. Huge variations were also found in 40 41 investment in healthcare, with the UK investing £3,257 per capita (9.8% of GDP), which is 42 43 18th of all OECD countries, despite being the fifth largest economy globally. This again 44 highlights how governments and society cannot ignore the informative value of price, costs
45 on October 1, 2021 by guest. Protected copyright. 46 and the value we assign to paramedic care in pandemics. Every aspect from pandemic 47 48 preparation and procurement of PPE to paramedic wellbeing may be informed by the price 49 we are prepared to pay, how we value health services and the subsequent costs involved. 50 51 Societies and governments will therefore continue to make tragic choices in this and future 52 53 pandemics in order to protect un-priceable lives. 54 55 56 Discussion 57 58 Due to the nature of EGTM, much of the discussion has been presented through narrative 59 60 within this paper. We have achieved our aim of exploring paramedic experiences of
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1 2 3 providing care during the 2020 COVID-19 pandemic and developing theory in order to 4 5 inform future policy and practice which has been called for in the literature [70]. Much of our BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 findings reflect what was already known from studies with HCW’s in previous pandemics 8 and may have been somewhat predictable. This highlights the need for pandemic planning 9 10 and responses to be informed by the best available evidence. Conducting research within this 11 12 context presented a unique opportunity, and through swift mobilisation of our research team, 13 14 development and approval of our study we were able to capture these data as the acute 15 pandemic period unfolded. We have learned much from our nimble and efficient approach to 16 17 this study which may benefit future research with paramedics and during such crises. 18 For peer review only 19 20 Paramedic participants within our study were extremely concerned about their own physical 21 22 safety and that of other family members which was articulated through the category Protect 23 me to protect you. Such safety concerns are consistent with reports from this and other 24 25 pandemics, and exacerbated by inadequate PPE, insufficient resources, and inconsistent 26 27 information [70]. Adequate supply and appropriately designed PPE for the prehospital setting 28 should be considered an urgent priority for the current and future pandemic. Whilst 29 30 participants were generally supportive of the information provided by their employer, they 31 32 reported limited trust in wider information sources, especially from media and politicians, 33 34 which could be a sources of support but also sources of stress as reported in this and other 35 studies [70]. Protecting paramedics in order to protect the public during pandemics should 36
37 therefore be a priority in this and future pandemics. http://bmjopen.bmj.com/ 38 39 Participant’s reports of their wellbeing and mental health being negatively affected are 40 41 consistent with other studies [51, 61, 66, 70]. Significant efforts had been made prior to 42 43 COVID-19 to improve mental health and wellbeing support for ambulance staff, which was 44 recognised by participants in our study. However, Clark et al (2021) [88] reported that despite 45 on October 1, 2021 by guest. Protected copyright. 46 a body of research on health and well-being of ambulance staff, there is little evidence on 47 48 whether current actions are working. Our study however may reflect some progress, as staff 49 50 talked openly about their mental health and wellbeing and gained support through colleagues, 51 52 friends and the service Chaplain. Formal occupational health support through their employers 53 however was not however generally valued or utilised, which is consistent with reports in the 54 55 literature [63]. This should be of concern, and we therefore support calls from Clark et al 56 57 (2021) [88] and others to further investigate strategies from an organisational and individual/ 58 social level. Such strategies should consider the positive impact of exercise and being in 59 60
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1 2 3 nature as reported in this study, which is known to support well-being and mental health [48- 4 5 51]. BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 The tragic choices reported within this study are influenced by ethical, moral and professional 8 9 dilemmas. Paramedics reported feeling they were unable to deliver the standard of care they 10 11 would usually provide, which has been reported in other studies, and may increase risk of 12 13 moral injury [45, 70]. It was acknowledged that moral injury during crises can result in post- 14 traumatic growth [34], and the many examples of rapid disruption and adaptation within this 15 16 study may reflect such growth, especially around decision making. It should however be 17 18 recognised that suchFor growth peerrelies on supportive review cultures, trainingonly and preparation to 19 overcome the negative emotional impact [35]. Future preparation for pandemics should 20 21 therefore consider the findings of this study and focus on such issues in planning. 22 23 24 Moral injury can be a risk factor for further mental health problems and Billings et al [70] 25 found it to be particularly pernicious in the context of COVID-19 and other pandemics, 26 27 where many HCW’s feel betrayed by their colleagues, organisations and society, some of 28 29 which may have also been reflected in this study. Paramedics in our study reported the sense 30 31 of being United in hardship, where the pandemic served as a unifying force in battling the 32 common enemy of COVID-19. This unity was displayed across the organisation and society 33 34 and even involved powerful militaristic metaphor such as ‘Call to arms’. We suggest 35 36 however that Tragic societal choices where revealed through this relationship employers,
37 society and government. http://bmjopen.bmj.com/ 38 39 40 Early on in the pandemic, some HCW’s including paramedics posted pictures and videos of 41 42 themselves on social media ranging from messages of protecting the NHS to highly 43 choreographed dances in clinical uniforms. Politicians, wider society and organisations also 44
45 publically showed their support through social media and campaigns such as NHS Heroes. on October 1, 2021 by guest. Protected copyright. 46 47 Whilst paramedics in our study were appreciative of this support, they reflected self- 48 deprecatory accounts reported in other studies of such heroic status, highlighting they were 49 50 doing their job [27] and above all wanted to protect themselves and their families. They 51 52 reported how they would be forgotten about by the public and return inappropriate use of 53 54 ambulances and violence and aggression directed towards them. As the pandemic unfolded, 55 some of these predictions were realised through reports of increased emergency are us during 56 57 drunken parties VE day celebrations [83, 84]. As we approached the anniversary of the 58 59 60
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1 2 3 pandemic, and look to recover, displays of unity within the media and literature may have 4 5 been replaced by a sense of betrayal of HCW’s [89, 90, 91]. BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 Powerful media and communication narrative and metaphor were employed during the 8 9 pandemic, revealing Tragic Societal Choices in relation to the relationship with paramedics 10 11 and other HCW’s. Militaristic, battle-like metaphors and unitedness in hardship within the 12 13 media appeared to be replaced by a polarised narrative in later stages of the pandemic. 14 Accusations have been made of a striking absence of any plan for long term recovery of 15 16 health and social care services from the pandemic in the UK Government 2021 budget, which 17 18 they argue is aimedFor at protecting peer the jobs review and livelihoods ofonly the British people [92, 93]. Gone 19 are the highly choreographed social media posts such as TIK-TOK items of NHS worker 20 21 dancing in clinical uniforms. #NHS Pay Twitter Hashtag dominates social media in later 22 23 stages of the pandemic [94]. Questions also remain around the influence of campaigns such 24 25 as the ’Stay Home, Protect the NHS, Save Lives’ [81] slogan, and if they were too successful 26 and scared accessing emergency care as reported in this study by Paramedics who reported 27 28 fear amongst patients in accessing emergency care. 29 30 31 32 Strengths and limitations 33 34 The study was conducted in one ambulance service and is therefore somewhat limited from 35 this perspective. Remarkable consistency and agreement was found throughout analysis, 36
37 member checking and previous studies which adds to the trustworthiness and transferability http://bmjopen.bmj.com/ 38 39 of our findings. Non-response bias may have occurred as participants may be more proactive, 40 and likely to engage in research. Using the VoIP of Skype™ was deemed a strength, despite 41 42 technical difficulties and one corrupted recording. The research team included insider 43 44 researchers with three practicing paramedics and whilst this may be considered a potential
45 on October 1, 2021 by guest. Protected copyright. 46 bias, we stated up front the constructivist nature of evolved grounded theory and how the 47 background of these researchers added to the richness of the GT. We also made extensive 48 49 reflective notes, cross validated coding and analysis and conducted member checking with a 50 51 very good response rate and heterogeneity in responses. 52 53 We were unable to involve patients and public in the study due to the speed of developments. 54 We do however plan to disseminate the results to study participants and patient organisations 55 56 57 Conclusion 58 59 60
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1 2 3 The COVID-19 pandemic is arguable the biggest challenge to have faced providers of 4 5 healthcare globally. Paramedics are at the forefront of the pandemic response, and this BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 research has revealed rich insights on their experiences, which are consistent with reports in 8 other studies with HCW’s in pandemics. We however synthesized emergent categories within 9 10 this study with the work of Calabresil and Bobbitt (1978) [23] and developed a new 11 12 theoretical context which richly articulates the range of issues faced by paramedics through 13 14 the constructed GT of ‘Tragic Choices in providing paramedic care during the 2020 COVID- 15 19 pandemic’. 16 17 18 Paramedics faced TragicFor Personal peer & professional review choices, only which included concerns over 19 appropriate PPE, protecting themselves and their relatives, the impact on their mental health 20 21 and difficult clinical decisions in areas such as EoLC and patients scared to attend hospital. 22 23 The rapid disruption and adaptation endured may represent significant organisational and 24 25 professional growth, which has been reported in previous pandemics and following trauma, 26 however accounts in this study may also reflect collective moral injury, which may persist 27 28 long after the pandemic. Tragic organisational choices were also revealed, around a culture 29 30 of support in areas such as clinical decision making, EoLC, communication, mental health 31 32 and wellbeing, and whilst somewhat forced, they are influenced by choices made to focus on 33 these areas before, during and after the pandemic. Organisations may choose to explore 34 35 further reports in our study of why paramedics did not engage in wellbeing support provided 36
37 by their employer, the role of incentives for working overtime in staff who may be fatigued http://bmjopen.bmj.com/ 38 during a pandemic, intrusive media reports which some avoided to protect their mental 39 40 health, and the positive role of being in nature and exercise. Much of our findings were 41 42 previously reported in the literature, and therefore when planning for future pandemics 43 44 organisations can also continue choose to draw upon this evidence base (or not).
45 on October 1, 2021 by guest. Protected copyright. 46 The relationship between society and paramedics was visibly played out, with public shows 47 48 of support through social media, the NHS Heroes narrative, clapping and gifts. Whilst 49 appreciative, paramedics told how they were just doing their job, and above all wanted to 50 51 protect themselves and their families. Paramedics predictions on how they would soon be 52 53 forgotten about by the public and return to inappropriate use of ambulances and violence and 54 55 aggression directed towards them, transpired during the pandemic through reports of 56 partying, and lack of social distancing VE day celebrations. We argue these issues reflect 57 58 Calabresil and Bobbitt’s notion that what counts as a tragic choice is in many ways a matter 59 60 of public drama, and society may have treated them as tragic, when in fact they need not be.
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1 2 3 Whilst much of the impact of COVID-19 may be unavoidable, society can choose to limit 4 5 spread of the disease by observing social distancing for instance. Much of our findings had BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 already been reported in literature from other HCW’s in previous pandemics, and whilst the 8 current response benefitted from these insights, warnings were made on the inevitability of 9 10 such a pandemic and how preparations should focus on issues of PPE, utilisation and 11 12 resourcing of health care, communication and staff wellbeing. A counter narrative 13 14 subsequently grew within our study and wider society, around these issues especially in later 15 stages which included healthcare funding and better pay for HCW’s. 16 17 18 Paramedic care duringFor the COVID-19 peer pandemic review was provided only in the context of a world with 19 competing and conflicting decisions and resources, where a wide range of Tragic Choices 20 21 have to be made which may challenge the pricelessness of life. It is therefore a disturbing, but 22 23 undeniable reality that such Tragic Choices have to be made. The impact of COVID-19 may 24 25 persist if we fail to learn from this and other pandemics and sufficiently resource our 26 healthcare system and provide the prerequisite supportive and safe workplaces, through 27 28 adequate supply of appropriate PPE, education, and provision of mental health and wellbeing 29 30 support. If not, we risk losing more lives in this and future pandemics, paradoxically 31 32 undermining life’s pricelessness and threatening the overwhelming collective effort which 33 united society in hardship when responding to the COVID-19 Pandemic. 34 35 36
37 Contributors: NR Led on preparing the manuscript. LS, CH and JW collaborated on the http://bmjopen.bmj.com/ 38 design, data collection and analysis, and all approved the final manuscript. 39 40 Funding: This research received no specific grant from any funding agency in the public, 41 42 commercial or not-for-profit sectors. 43 44 Competing interests: NR, CH and LS are employees of WAST
45 Disclaimer: The views and opinions expressed therein are those of the authors and do not on October 1, 2021 by guest. Protected copyright. 46 47 necessarily reflect those of WAST 48 49 Data availability statement: Data are available from the authors on request 50 51 Acknowledgments: The authors would like to thank all of the paramedics who participated 52 in this study and WAST for sponsoring 53 54 55 56 57 58 59 60
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1 2 3 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 References 7 8 1. Coronavirus Disease (COVID-19) Situation Reports [Internet]. Who.int. 2020 [cited 9 10 13 January 2021]. Available from: https://www.who.int/emergencies/diseases/novel- 11 12 coronavirus-2019/situation-reports 13 14 2. Coronavirus disease (COVID-19) – World Health Organization [Internet]. Who.int. 15 2020 [cited 13 January 2021]. Available from: 16 17 https://www.who.int/emergencies/diseases/novel-coronavirus-2019 18 For peer review only 19 3. UK G. Number of coronavirus (COVID-19) cases and risk in the UK. online: 20 https://www. gov. uk/guidance/coronavirus-covid-19-information-for-the-public. 21 22 2020a 23 24 4. UK G. Coronavirus (COVID-19) action plan [Internet]. GOV.UK. 2020b [cited 13 25 26 January 2021]. Available from: 27 https://www.gov.uk/government/publications/coronavirus-action-plan 28 29 5. Davies, K. Higginson, R. (2005) Evolution and healthcare impact of a 21st Century 30 31 avian flu pandemic. British Journal of Nursing. Vol 14, No 20 32 6. 33 Juszczyk J (2004) Global strategies in prevention of infectious diseases on the turn of 34 the second and third millennium: expectation versus reality. Przegl Epidemiol 35 36 58(Suppl 1): 5–9 (in Polish)
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1 2 3 workers in a tertiary hospital. The British Journal of Psychiatry. 2004 4 5 Aug;185(2):127-33. BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 11. Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological 8 impact of COVID-19 beyond paranoia and panic. Ann Acad Med Singapore. 2020 Jan 9 10 1;49(1):1-3. 11 12 12. Tiong WW, Koh GC. Ethical considerations in the review of Singapore’s H1N1 13 14 pandemic response framework in 2009. Annals of the Academy of Medicine, 15 Singapore. 2013 May 1;42(5):246-50. 16 17 13. Hogan, C. Williams, J. Rees, N. (2021) Review of the literature concerning Health 18 For peer review only 19 Care workers’ experiences during epidemics and pandemics in relation to the COVID 20 21 19 response. International Journal of Paramedic Practice. In Press 22 14. Strauss, A. Corbin, J. (1998). Basics of qualitative research: Techniques and 23 24 procedures for developing grounded theory. (2nd ed.). Thousand Oaks, CA: Sage. 25 15. Charmaz K. Constructing grounded theory: A practical guide through qualitative 26 27 analysis. sage; 2006 Jan 13. 28 16. Guba, E. G., & Lincoln, Y. S. (2005). Paradigmatic Controversies, Contradictions, 29 30 and Emerging Confluences. In N. K. Denzin & Y. S. Lincoln (Eds.), The Sage 31 handbook of qualitative research (p. 191–215). Sage Publications Ltd. 32 17. Strauss A, Corbin J. Basics of qualitative research. Sage publications; 1990. 33 18. Iacono VL, Symonds P, Brown DH. Skype as a tool for qualitative research 34 35 interviews. Sociological Research Online. 2016;21(2):1-2. 36 19. Glaser B, Strauss AL. The Discovery of Grounded Theory Chicago: Aldine. 1967
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1 2 3 25. Rankin LE, Eagly AH. Is his heroism hailed and hers hidden? Women, men, and the 4 5 social construction of heroism. Psychology of Women Quarterly. 2008 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 Dec;32(4):414-22. 8 26. Franco, Z., Blau, K., Zimbardo, P. G. (2011). Heroism: A conceptual analysis and 9 10 differentiation between heroic action and altruism. Review of General Psychology, 11 12 15(2), 99-113. 13 14 27. Tangherlini TR. Heroes and lies: storytelling tactics among paramedics. Folklore 15 2000;111:43–66. 16 17 28. Jones-Berry S. COVID-19: nurses receive conflicting advice on PPE and resuscitation 18 For peer review only 19 [Internet]. Rcni.com. 2020 [cited 13 January 2021]. Available from: 20 21 https://rcni.com/nursing-standard/newsroom/news/covid-19-nurses-receive- 22 conflicting-advice-ppe-and-resuscitation-159701 23 24 29. Anderson N, Slark J, Gott M. How are ambulance personnel prepared and supported 25 26 to withhold or terminate resuscitation and manage patient death in the field? A 27 scoping review. Australasian Journal of Paramedicine [Internet]. 2019Jul.11 [cited 28 29 2021Jan.13];160. Available from: 30 31 https://ajp.paramedics.org/index.php/ajp/article/view/697 32 33 30. Pease NJ, Sundararaj JJ, O'Brian E, Hayes J, Presswood E, Buxton S. Paramedics and 34 serious illness: communication training. BMJ Supportive & Palliative Care. 2019 Nov 35 36 15.
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1 2 3 36. Spronk B, Stolper M, Widdershoven G. Tragedy in moral case deliberation. Medicine, 4 5 health care and philosophy. 2017 Sep 1;20(3):321-33. BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 37. Hoffmaster B, Hooker C. Tragic choices and moral compromise: the ethics of 8 allocating kidneys for transplantation. The Milbank Quarterly. 2013 Sep;91(3):528-57 9 10 38. Amerio A, Bianchi D, Santi F, Costantini L, Odone A, Signorelli C, Costanza A, 11 12 Serafini G, Amore M, Aguglia A. Covid-19 pandemic impact on mental health: a 13 14 web-based cross-sectional survey on a sample of Italian general practitioners. Acta 15 Bio Med [Internet]. 2020May11 [cited 2021Jan.13];91(2):83-8. Available from: 16 17 https://www.mattioli1885journals.com/index.php/actabiomedica/article/view/9619 18 For peer review only 19 39. Wang L, He W, Yu X, Hu D, Bao M, Liu H, Zhou J, Jiang H. Coronavirus disease 20 21 2019 in elderly patients: Characteristics and prognostic factors based on 4-week 22 follow-up. Journal of Infection. 2020 Mar 30 23 24 40. Li P, Chen L, Liu Z, Pan J, Zhou D, Wang H, Gong H, Fu Z, Song Q, Min Q, Ruan S. 25 26 Clinical Features and Short-term Outcomes of Elderly Patients With COVID-19. 27 International Journal of Infectious Diseases. 2020 May 31. 28 29 41. Straus SE, Wilson K, Rambaldini G, Rath D, Lin Y, Gold WL, Kapral MK. Severe 30 31 acute respiratory syndrome and its impact on professionalism: qualitative study of 32 33 physicians' behaviour during an emerging healthcare crisis. Bmj. 2004 Jul 34 8;329(7457):83. 35 36 42. Chao, D. (2003). Time to show unity against SARS. Bmj, 326(7395), 938.
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1 2 3 47. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health 4 5 challenges faced by healthcare workers during covid-19 pandemic. bmj. 2020 Mar BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 26;368. 8 48. Howell AJ, Passmore HA. The nature of happiness: Nature affiliation and mental 9 10 well-being. InMental well-being 2013 (pp. 231-257). Springer, Dordrecht. 11 12 49. Russell R, Guerry AD, Balvanera P, Gould RK, Basurto X, Chan KM, Klain S, 13 14 Levine J, Tam J. Humans and nature: how knowing and experiencing nature affect 15 well-being. Annual Review of Environment and Resources. 2013 Oct 17;38:473-502. 16 17 50. Gritzka S, MacIntyre TE, Dörfel D, Baker-Blanc JL, Calogiuri G. The effects of 18 For peer review only 19 workplace nature-based interventions on the mental health and well-being of 20 21 employees: a systematic review. Frontiers in psychiatry. 2020;11. 22 51. Brymer E, Freeman DE, Richardson M. One health: The wellbeing impacts of human- 23 24 nature relationships. Frontiers in psychology. 2019;10:1611. 25 26 52. Cortez RM, Johnston WJ. The Coronavirus crisis in B2B settings: Crisis uniqueness 27 and managerial implications based on social exchange theory. Industrial Marketing 28 29 Management. 2020 Jul 1;88:125-35. 30 31 53. Kabadayi S, O’Connor GE, Tuzovic S. The impact of coronavirus on service 32 33 ecosystems as service mega-disruptions. Journal of Services Marketing. 2020 May 28. 34 54. Heinonen K, Strandvik T. Reframing service innovation: COVID-19 as a catalyst for 35 36 imposed service innovation. Journal of Service Management. 2020 Sep 15.
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1 2 3 60. Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome 4 5 coronavirus 2 (SARS-CoV-2) and corona virus disease-2019 (COVID-19): the BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 epidemic and the challenges. International journal of antimicrobial agents. 2020 Feb 8 17:105924. 9 10 61. Rossi R, Socci V, Pacitti F, Di Lorenzo G, Di Marco A, Siracusano A, Rossi A. 11 12 Mental Health Outcomes Among Frontline and Second-Line Health Care Workers 13 14 During the Coronavirus Disease 2019 (COVID-19) Pandemic in Italy. JAMA 15 Network Open. 2020 May 1;3(5):e2010185-. 16 17 62. Kisely S, Warren N, McMahon L, Dalais C, Henry I, Siskind D. Occurrence, 18 For peer review only 19 prevention, and management of the psychological effects of emerging virus outbreaks 20 21 on healthcare workers: rapid review and meta-analysis. bmj. 2020 May 5;369. 22 63. Chen, C. L. (2004). Psychological impact of severe acute respiratory syndrome on 23 24 health workers in a tertiary hospital. The British Journal of Psychiatry, 185(2), 127- 25 26 133. 27 64. Rose, S., Bisson, J., Churchill, R., & Wessely, S. (2002). Psychological debriefing for 28 29 preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic 30 31 Reviews (Online), (2)(2). 32 33 65. NICE (2018) Evidence | Post-traumatic stress disorder | Guidance | NICE [Internet]. 34 Nice.org.uk. 2018 [cited 13 January 2021]. Available from: 35 36 https://www.nice.org.uk/guidance/ng116/evidence/
37 http://bmjopen.bmj.com/ 38 66. Holmes, Emily A et al. Multidisciplinary research priorities for the COVID-19 39 pandemic: a call for action for mental health science The Lancet Psychiatry, Volume 40 7, Issue 6, 547 - 560 41 67. Kleppa E, Sanne B, Tell GS. Working overtime is associated with anxiety and 42 43 depression: the Hordaland Health Study. Journal of occupational and environmental 44 medicine. 2008 Jun 1;50(6):658-66. 45 on October 1, 2021 by guest. Protected copyright. 46 68. Kok BC, Herrell RK, Grossman SH, West JC, Wilk JE. Prevalence of professional 47 48 burnout among military mental health service providers. Psychiatric Services. 2016 49 50 Jan 1;67(1):137-40. 51 52 69. Wong K, Chan AH, Ngan SC. The effect of long working hours and overtime on 53 occupational health: a meta-analysis of evidence from 1998 to 2018. International 54 55 journal of environmental research and public health. 2019 Jan;16(12):2102. 56 57 70. Billings, J. Ching, B.C.F. Gkofa1, V. Greene, T. Bloomfield, M (2020) Healthcare 58 workers’ experiences of working on the frontline and views about support during 59 60
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1 2 3 COVID-19 and comparable pandemics: A rapid review and meta-synthesis. medRxiv 4 5 preprint doi: https://doi.org/10.1101/2020.06.21.20136705. BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 71. Ardebili, M.E. Naserbakht, M. Colleen, B. C. Alazmani-Noodeh, F. Hakimi, H. 8 Ranjbar, H. (2020) Healthcare providers experience of working during the COVID-19 9 10 pandemic: A qualitative study. AJIC: American Journal of Infection Control (2020), 11 12 doi: https://doi.org/10.1016/j.ajic.2020.10.001 13 14 72. BMA survey finds doctors' lives still at risk despite PPE pledges [Internet]. The 15 British Medical Association is the trade union and professional body for doctors in the 16 17 UK. 2021 [cited 13 January 2021]. Available from: https://www.bma.org.uk/bma- 18 For peer review only 19 media-centre/bma-survey-finds-doctors-lives-still-at-risk-despite-government- 20 21 pledges-on-ppe 22 73. Horton R. Offline: COVID-19 and the NHS—“a national scandal”. Lancet (London, 23 24 England). 2020 Mar 28;395(10229):1022. 25 26 74. Bradsher K, Alderman L. The world needs masks. China makes them—but has been 27 hoarding them. New York Times. 2020 Mar 16;13. 28 29 75. Scally G, Jacobson B, Abbasi K. The UK’s public health response to covid-19. 2020 30 31 76. Nuki P, Gardner B. Exercise Cygnus uncovered: the pandemic warnings buried by the 32 33 the government. The Telegraph. 28 March 2020. Available from: 34 https://www.telegraph.co.uk/news/2020/03/28/exercise-cygnus-uncovered-pandemic- 35 36 warnings-buried-government/ [Acessed on 14/12/2020]
37 http://bmjopen.bmj.com/ 38 77. Morris J. What has been the impact of Covid-19 on urgent and emergency care across 39 40 England. Nuffield Trust. 2020a. Disponível em: https://www. nuffieldtrust. org. 41 uk/news-item/what--has-been-the-impact-of-covid-19-on-urgent-and-emergency-care- 42 43 across-england. Acesso em 1º de setembro de. 2020. 44 78. Missing reference - Moore 2020 45 on October 1, 2021 by guest. Protected copyright. 46 79. WG (2020) Record high demand on ambulance and Emergency Departments during 47 48 challenging December | GOV.WALES [Internet]. GOV.WALES. 2020 [cited 13 49 50 January 2021]. Available from: https://gov.wales/record-high-demand-ambulance- 51 52 and-emergency-departments-during-challenging-december 53 80. Welsh Ambulance Service NHS Trust: The Performance Report [Internet]. 54 55 Ambulance.wales.nhs.uk. 2018 [cited 13 January 2021]. Available from: 56 57 https://www.ambulance.wales.nhs.uk/assets/documents/7d0c97f9-b562-4f95-9af6- 58 2200c642e3b7636670743715317704.pdf 59 60
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1 2 3 81. Hope C, Dixon H. (2020) The story behind ’Stay Home, Protect the NHS, Save 4 5 Lives’—The slogan that was ‘too successful’. The Telegraph. 2020 May; BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 82. Wong, L.E. Hawkins, J.E. Langness, S. Iris, P. Murrell Sammann, A. (2020) Where 8 Are All the Patients? Addressing Covid-19 Fear to Encourage Sick Patients to Seek 9 10 Emergency Care. New Englan Journal of Medicine. May 2020 11 12 83. Coronavirus: NHS staff fear second wave after VE Day parties [Internet]. BBC News. 13 14 2021 [cited 13 January 2021]. Available from: https://www.bbc.co.uk/news/uk-wales- 15 52608132?at_campaign=64& 16 17 84. ONeill R. Senior doctors fear coronavirus second wave after drunken VE Day parties 18 For peer review only 19 [Internet]. Wales Online. 2020 [cited 13 January 2021]. Available from: 20 21 https://www.walesonline.co.uk/news/wales-news/doctor-street-parties-lockdown- 22 coronavirus-18228839. 23 24 85. Manning A. How will Covid-19 shape the future economic role of the British state?. 25 26 LSE Business Review. 2020 May 20. 27 86. Give NHS workers a pay rise as well as a clap | Letters [Internet]. the Guardian. 2020 28 29 [cited 13 January 2021]. Available from: 30 31 https://www.theguardian.com/society/2020/apr/27/give-nhs-staff-a-pay-rise-not-just- 32 33 a-clap 34 87. OECD Healthcare Salary Index by Qunomedical [Internet]. Qunomedical.com. 2020 35 36 [cited 13 January 2021]. Available from:
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45 on October 1, 2021 by guest. Protected copyright. 46 89. Berger, D. (2021) Up the line to death: covid-19 has revealed a mortal betrayal of the 47 world’s healthcare workers. BMJ. January 29, 2021 48 49 90. Mohammed, S. Peter, E. Killackey, T. Maciver, J. (2021) The “nurse as hero” 50 51 discourse in the COVID-19 pandemic: A poststructural discourse analysis. 52 53 International Journal of Nursing Studies. Vol 117. 54 91. Booth, R. Butler, P. Campbell, D. (2021) NHS, social care and most vulnerable 55 56 57 'betrayed' by Sunak's budget. Available from: https://www.theguardian.com/uk- 58 59 60
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1 2 3 news/2021/mar/03/nhs-social-care-and-most-vulnerable-betrayed-by-sunaks-budget. 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 Guardian Newspaper. [Accessed on 3 Mar 2021] 7 8 92. Dowd A. (2021) Covid-19: Budget has failed to provide recovery funding for NHS, 9 10 health leaders warn. BMJ 2021; 372 :n633 doi:10.1136/bmj.n633 11 12 13 93. HM Treasury. Available from: Budget (2021) Protecting the jobs and livelihoods of 14 15 the British people. 3 Mar 2021. https://www.gov.uk/government/publications/budget- 16 17 18 2021-documentsFor [Accessed peer on 4th review March 2021] only 19 20 94. #NHS Pay (2021) NHS Pay Twitter Hashtag. Available from: 21 22 https://twitter.com/hashtag/nhspayrise?lang=en [Accessed on 28/03/2021] 23 24 25 26 27 28 29 30 sp2122 31 32 33 34 35 36
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1 2 3 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 7 8 9 10 11 12 13 14 15 16 17 18 For peer review only 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
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PECC-19 Interview guide V 3.0 1 IRAS ID: 282623 Date:03/04/2020 2
3 4 5 BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 6 Paramedic Experiences of providing Care during the 7 8 2020 COVID-19 Pandemic (PECC-19): 9 10 A qualitative study using Grounded Theory 11 12 13 Interview Guide 14 15 Interview Guide 16 Introduction Key components: I want to thank you for taking the time to meet with me today. My 17 Thank you name is Dr Nigel Rees and we are here to Paramedic experiences 18 • Your name, purpose, confidentialityFor, peerof providing review care during the 2020 only COVID-19 Pandemic. 19 20 duration, how interview will 21 be conducted, opportunity for questions, Can I confirm that you have read the information sheet and 22 signature of consent form understand the purpose of the research? 23 Questions: 1. Can you tell me what you know/understand about COVID-19? 24 2. Tell me about your experiences of providing paramedic care 25 during the COVID-19 Pandemic? 26 3. Have you felt scared or anxious, and has your morale, mental 27 health or wellbeing been affected the COVID-19 Pandemic 28 29 4. Has the COVID-19 Pandemic impacted on your personal or 30 family life? 31 5. How do you look after yourself following during the COVID-19 32 Pandemic? 33 6. What are your thoughts of the risk of infection with COVID- 34 19? 35 7. Do you feel you have been provided with adequate training, 36 and equipment for this situation?
37 http://bmjopen.bmj.com/ 38 8. What are your experiences from an occupational health 39 perspective; i.e. assessment, absence, mental health and 40 wellbeing support and pay related issues? 41 9. Do you feel you have been kept informed and updated and 42 supported as the COVID-19 Pandemic has progressed? 43 10. What are your thoughts on the NHS Heroes campaign ongoing 44 during the COVID-19 Pandemic?
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COREQ (COnsolidated criteria for REporting Qualitative research) Checklist BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 1
2 3 A checklist of items that should be included in reports of qualitative research. You must report the page number in your manuscript 4 where you consider each of the items listed in this checklist. If you have not included this information, either revise your manuscript 5 accordingly before submitting or note N/A. 6 7 Topic Item No. Guide Questions/Description Reported on 8 Page No. 9 10 Domain 1: Research team 11 and reflexivity 12 Personal characteristics 13 Interviewer/facilitator 1 Which author/s conducted the interview or focus group? 14 Credentials 2 What were the researcher’s credentials? E.g. PhD, MD 15 16 Occupation For3 Whatpeer was their occupationreview at the time only of the study? 17 Gender 4 Was the researcher male or female? 18 Experience and training 5 What experience or training did the researcher have? 19 Relationship with 20 participants 21 22 Relationship established 6 Was a relationship established prior to study commencement? 23 Participant knowledge of 7 What did the participants know about the researcher? e.g. personal 24 the interviewer goals, reasons for doing the research 25 Interviewer characteristics 8 What characteristics were reported about the inter viewer/facilitator? 26 e.g. Bias, assumptions, reasons and interests in the research topic 27 28 Domain 2: Study design 29 Theoretical framework 30 Methodological orientation 9 What methodological orientation was stated to underpin the study? e.g. 31 and Theory grounded theory, discourse analysis, ethnography, phenomenology, 32 content analysis 33 http://bmjopen.bmj.com/ 34 Participant selection 35 Sampling 10 How were participants selected? e.g. purposive, convenience, 36 consecutive, snowball 37 Method of approach 11 How were participants approached? e.g. face-to-face, telephone, mail, 38 email 39 40 Sample size 12 How many participants were in the study?
41 Non-participation 13 How many people refused to participate or dropped out? Reasons? on October 1, 2021 by guest. Protected copyright. 42 Setting 43 Setting of data collection 14 Where was the data collected? e.g. home, clinic, workplace 44 Presence of non- 15 Was anyone else present besides the participants and researchers? 45 46 participants 47 Description of sample 16 What are the important characteristics of the sample? e.g. demographic 48 data, date 49 Data collection 50 Interview guide 17 Were questions, prompts, guides provided by the authors? Was it pilot 51 52 tested? 53 Repeat interviews 18 Were repeat inter views carried out? If yes, how many? 54 Audio/visual recording 19 Did the research use audio or visual recording to collect the data? 55 Field notes 20 Were field notes made during and/or after the inter view or focus group? 56 Duration 21 What was the duration of the inter views or focus group? 57 58 Data saturation 22 Was data saturation discussed? 59 Transcripts returned 23 Were transcripts returned to participants for comment and/or 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 39 of 38 BMJ Open
Topic Item No. Guide Questions/Description Reported on BMJ Open: first published as 10.1136/bmjopen-2021-048677 on 17 June 2021. Downloaded from 1 Page No. 2 3 correction? 4 Domain 3: analysis and 5 findings 6 Data analysis 7 Number of data coders 24 How many data coders coded the data? 8 9 Description of the coding 25 Did authors provide a description of the coding tree? 10 tree 11 Derivation of themes 26 Were themes identified in advance or derived from the data? 12 Software 27 What software, if applicable, was used to manage the data? 13 Participant checking 28 Did participants provide feedback on the findings? 14 15 Reporting 16 Quotations presented For29 Werepeer participant review quotations presented only to illustrate the themes/findings? 17 Was each quotation identified? e.g. participant number 18 Data and findings consistent 30 Was there consistency between the data presented and the findings? 19 Clarity of major themes 31 Were major themes clearly presented in the findings? 20 21 Clarity of minor themes 32 Is there a description of diverse cases or discussion of minor themes? 22 23 Developed from: Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist 24 for interviews and focus groups. International Journal for Quality in Health Care. 2007. Volume 19, Number 6: pp. 349 – 357 25
26 27 Once you have completed this checklist, please save a copy and upload it as part of your submission. DO NOT include this 28 checklist as part of the main manuscript document. It must be uploaded as a separate file. 29 30 31 32
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41 on October 1, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml