Factors affecting the retention of paramedics within the Ambulance Services

Liz Harris FCPara, Head of Professional Standards for the College of Paramedics writes a short blog based on the presentation she delivered at the Association of Ambulance Chief Executives, Ambulance Leadership Forum in March 2019 detailing the findings of a study on ambulance service retention carried out in 2016.


The methodology for the study included a Literature Search, a review of several national publications and a selection of Human Resources Management texts. Specific data from four sources of secondary data was also used, including the College of Paramedics Recruitment and Retention survey conducted in 2015 (unpublished). This survey had 977 responses of which 238 were from individuals who had left an Ambulance Service in the preceding 24 months. 

Four key themes emerged that could potentially impact on an individual’s intention to leave their employment: 

The College of Paramedics survey asked what would contribute towards the ability of ambulance services to retain existing staff? Improvements in career progression, training and access to continued professional development were mentioned by the highest number of respondents. The lack of training and development has two main consequences; Firstly, paramedics are leaving to pursue development and new opportunities outside of the ambulance service, which is reducing the qualified and experienced workforce numbers. Secondly, the paramedics that remain are experiencing a change to the type of workload that they most consistently experience but are not historically trained to deal with, this without any ongoing training and development is negatively affecting their confidence and job satisfaction. 

Paramedics take a great deal of satisfaction from the job that they do and are proud of the care that they can give but the intense pressure, increasing workload, including shift over-run and shift patterns also left them feeling exhausted. Mopping up was mentioned, when other areas of the NHS are struggling, the Ambulance Service always responds and attempts to pick up the pieces. This leads to a feeling of ‘lack of respect’; being undervalued. Another challenge was mentioned, that some paramedics had come to the conclusion that dealing with and coping with difficult and/or mediocre colleagues had just become a way of life and to a certain extent accepted as the way it is. It was better to keep your head down and keep off the radar that raise concerns. A move towards peer review and supportive clinical supervision that allows a safe space for positive sharing of experiences and learning would have beneficial effects on staff’s work experiences. Communication was mentioned frequently in the literature and from all the data sources, poor communication was at the top of the list for workplace features that were reported most frequently as having a negative effect on staff’s well-being.  Email communication seemed to be the preferred method used by employers, but this was not at all sufficient and there was no time for operational staff to read them. Only 12% of staff reported having good communications with senior management.

Lack of management support was the reason given for leaving an Ambulance Service by the greatest number of respondents in the College of Paramedics survey. Unsupportive management was one workplace feature in particular that had the most significant detrimental impact on staff well-being. Historically management within ambulance services is geared towards vocational ambulance staff that has stayed within the same service for their whole career. Now new paramedics join ambulance services directly from academic institutes, they are young and a more mobile workforce, with less loyalty towards their employer. This change in workforce represents a challenge for some existing management cultures within ambulance services. Staff reported that promotion occurs ‘through the ranks’, with a focus on achievement of performance targets not on delivering clinical quality. An additional complexity is the expanding clinical and professional context and the increasing autonomy of the modern paramedic clashing with traditional command and control management cultures. A lack of formal management training may contribute to what is perceived as inattentive behaviours of managers and a lack of employee engagement. 

Much of the Human Resources Management text discusses pay and the impact of salary on retention at length, but the evidence in the papers, reviewed within this study, specific to emergency personnel suggests that pay only becomes an issue when other aspects of the job are impacting negatively upon the individual or when job satisfaction is low. Pay, was highlighted in the College of Paramedics survey as a reason for leaving and as a potential tool for retaining existing staff. Evidence from Australia indicates that the new graduate paramedics will seek out employment that suits their professional aspirations and their personal needs such as flexible hours and adequate pay. It is therefore necessary to get pay appropriate for the role, but the benefits will be short-lived without improvements in the other three key themes discussed within this study. 

To conclude…
Job satisfaction has been high for paramedics for many years due to the nature of the work, and pride in a job means that people tend to stick with it. Now, however, it appears that the negative impact of some of the other issues are having an effect on how paramedics feel about themselves, their work, their role and their employer. Paramedics often rely upon camaraderie to reduce the innate stresses of the work but due to the increasing workload and changing work practices this coping mechanism is now in short supply. Moving from an environment where underachievement of performance targets is constantly highlighted with blame apportioned, to a culture where learning is shared and people and positives are celebrated, would greatly increase staff satisfaction and wellbeing, and potentially subdue any intention to leave. Arguably Ambulance Services have relatively little influence on the external pull factors that cause paramedics to leave but can certainly work towards reducing the internal factors that push paramedics towards the exit, in particular by investing in their staff’s wellbeing and ongoing professional development. The impact of managers on staff wellbeing and their desire to leave an Ambulance Service should not be underestimated. All the findings within this study highlight a situation that links unsupportive managers with dissatisfied staff. This is a key point, not least because supporting managers to improve their knowledge, skills and behaviours is within the capability of all Ambulance Services.

Liz Harris
Head of Professional Standards, College of Paramedics