I'm always fascinated by the interaction between paramedics and ED personnel. Most of the time it's quite friendly. But look a bit deeper, and you can see the signs of strain, see the eyes roll and hear the sighs.
"Silly nurses don't understand what we go through in the field."
" Stupid paramedics don't know what they're doing, dumping on us again."
There's a baseline unease there, an unhappy relationship papered over by smiles and coffee. And try as we might, through education and interchange, the fracture never fully heals.
If you don't recognize this tension, you've not been in EMS very long. But did you ever wonder why, despite your efforts to be unerringly cheerful when needed and apologetic when required, they still don't seem to like you? Fortunately for you, I have the answer here, in an envelope which has been sealed in a suction unit for the past 30 days. And the answer is ... organizational culture.
If it's true that "culture" is an overused term in our pluralistic society, then the term "organizational culture" may be greeted with a certain amount of skepticism. However, the context of their use seems to differ. "Culture" (defined as the enduring behaviors, ideas and traditions shared by a large group of people and transmitted from one generation to next) is used as a means to positively define behaviors and beliefs. By contrast, "organizational culture" (the dominant pattern of basic assumptions, perceptions, thoughts, feelings and attitudes held by members of an organization) may be regarded as either a positive or negative feature of an organization.
Every organization, whether professional or social, has some type of organizational culture. Organizational culture is not necessarily discrete to any particular body or structure. For example, a set of hospitals may each exhibit a separate and distinct organizational culture. But within this set, administrators, physicians and nursing staff in different hospitals may hold more commonalties in values, beliefs and norms than with other employees in the same facility. Paramedics and EMT's may work for different agencies, but often share a similar professional culture.
The culture of EMS providers between agencies is often more similar to one another than they are to other emergency caregivers, especially those who are exclusively hospital-based. To put it bluntly, they don't like you because they don't understand you, and you eye them with suspicion because you don't understand them. As an American, you might live in France for 50 years. Nonetheless, you'll always be an American. If you're not inculcated into a culture during the formative years, you simply won't get it. The same is true when applied to the formation of a professional career.
Prehospital caregivers face a wide range of clinical scenarios during their professional lives. Some of the most challenging cases involve caring for the victim of asystolic cardiac arrest. I'd like to use this clinical scenario as a vehicle for exploring the organizational culture of EMS. The culture of EMS is best viewed through the lens of specific cultural components. These components include value orientations, basic assumptions, values, beliefs, norms and artifacts. Regardless of whether you recognize your service in these descriptions, or if you even agree with my characterizations, I hope the discussion provides a framework for your own thoughts.
In general, the value orientations of prehospital care providers appear to parallel those found in Western society. The character of their work indicates a desire to exhibit mastery over nature. The work profile would also indicate that they are oriented in "real time" to the present, as patient-care activities are performed without any expectation of future involvement or reward. Their view of the nature of human relationships is bimodal. All recognize the importance of the group effort, but concurrently labor to succeed within a competitive process for promotion that recognizes individual excellence. They have a strong desire to do rather than to think, to be or to plan.
In thought, prehospital care providers strive to be rationalists, looking to science to provide them with further knowledge about the mechanisms of the universe. This desire for truth and order contrasts with a strong underlying tendency to pessimism in the minds of these EMS workers. The random nature of events witnessed by these professionals, the negative ("evil") nature of these events upon life and property and the recognition of a need for compassion in the face of tragedy are all consistent with this pessimism. Operationally, EMS providers may be considered pragmatists, characterized by a focus on the workability of ideas, a lack of metaphysical insight and the use of ideas as tools for action.
Implicit within any organization is a series of unquestioned assumptions governing the manner in which the organization should address itself to both internal issues and the world at large. These assumptions are universally accepted within the group and are not subject to serious questioning or debate.
There are a number of basic assumptions underlying all aspects of EMS care. A primary proposition is the concept that a call to 9-1-1 is not only a call for help, but permission for care. A corollary to this assumption is the notion that the paramedic's dictates must be unquestioningly accepted by the patient and that patients and family members should be grateful for care. Paramedics and EMTs often become dismayed when patients call 9-1-1 for convenience rides or assists to bed, when patients attempt to dictate the terms of their own care or when care is first accepted and then refused.
A second assumption is that a designated individual will always be in charge of the patient care encounter. By their nature, EMS and fire agencies are hierarchical organizations. There is always the expectation that an individual will be in charge and that this person will provide direction to subordinates. While "group think" is not discouraged per se, the time frame in which care is provided does not permit moments for thought, reflection and discussion. Intimately linked to this concept of responsibility for care is the idea that whoever gets to the scene first is in charge. Difficulties arise when more than one agency is involved in a response, when multiple officers of equal rank are on scene, or when responders differ in care plans. This assumption of a need for hierarchy extends to policy and procedure as well. Independent decision-making is discouraged and must always be justified. The way to succeed is not to excel, but to not cause problems. Negative feedback is often considered the only feedback one might expect during a career in prehospital care.
A final assumption devolves from the process of operating in the "real-time" present. This results in the "here and now" being the only outcome of import. EMS personnel often show no interest in follow-up care, and when care is well performed in the field but the patient dies in the hospital, the patient will nonetheless be considered an EMS "save." (This assumption, unquestioned for many years, is beginning to change as operational and economic concerns force EMS providers to demonstrate the efficacy and cost-efficiency of their efforts.)
A value may be defined as a "conception of what is and is not desirable." Virtually any behavior or idea may be considered as a value. Values by themselves have no positive or negative implication, but find meaning in application.
Mission statements are declarations of the values of an organizational culture. When formulated with sincerity and based upon value orientations, they elevate a set of ideal behaviors as goals for organizational conduct. Mission statements often reflect common Western value orientations with emphasis on the active voice, future needs and a focus on the individual as the primary component of change.
The values of agencies that respond to EMS calls may vary, and this variance may lead to significant changes in care plans, attitudes and behaviors between these services. If the primary mission of a fire service is fire suppression, this value will dictate station placement, staffing, budgeting and internal attitudes toward EMS operations. All of these factors may exert an influence upon patient care. In the case of asystolic cardiac arrest, a fire station may be placed appropriately to respond within a reasonable time frame to a structure fire, but not to a patient's apartment in a large complex. A firefighter who becomes a paramedic primarily to earn an increase in salary may not provide as aggressive or informed care as one whose agency allows paramedics to climb a career ladder.
Several values appear to exhibit general application to EMS services. The primary mission, or primary value, appears to be the preservation of life. This value is considered independent of the mechanism of then threat to life. Providers would not place a priority of value upon a life endangered by fire over one endangered by a medical emergency (interestingly, however, it is often assumed that given a single fire service resource to devote to either a fire call or an EMS response, the unit would be used to respond to the fire).
While individual achievement is valued, this value is limited to the context of a single agency. Loyalty to an agency, as well as corollary hostility toward other agencies, also appears to be a prominent value shared by prehospital caregivers. In the experience of this author in working with EMS services, this loyalty results in significant attribution errors, where members of other organizations with positive input are considered not to be offering aid, but attempting to tear down another agency.
Organizational values also determine the paramedic's approach to cardiac arrest and death. EMS providers share a general agreement that death should be treated with dignity and that EMS providers should respond to cardiac arrest and death scenes with competence, tact and professionalism. Making a difference in patient care is another shared value, but this exists with the caveat that the effect is focused upon the prehospital encounter. Improvement or change in long-term outcome does not appear to be within the value structure of the service paramedic. Finally, many EMS services are adapting a paradigm featuring customer service as a primary value rather than focusing on a specific parameter such as response times or staffing levels as measures of effect.To be continued