‘When you’re wearing your uniform, you know misery might happen’
-A qualitative study on how paramedics experience and deal with threatening situations during work
Marlou Koch 10533532 Master Thesis
MSc Sociology: General Track Graduate School of Social Sciences
University of Amsterdam 1st supervisor: Dr. D. Weenink
2nd supervisor: Ms M. D. Cottingham
‘When you’re wearing your uniform, you know misery might happen.’ (Harry, respondent 10b)
Table of Contents Acknowledgements ... 4 Abstract ... 5 1. Introduction... 6 2. Theoretical Framework ... 9 2.1 Face-work ... 9 2.2 Impression management ... 11
2.3 Emotion work and emotional labour ... 11
2.4 Falling out of the landscape ... 13
2.5 Resume: integrating the theoretical concepts ... 14
3. Methodology ... 16
3.1 Data collection ... 16
3.1.1 Interviews ... 16
3.1.2 Observational participation ... 17
3.1.3 Private note of respondent ... 19
3.2 Sampling ... 19
3.3 Data analysis ... 21
3.4 Limitations ... 22
4. Ethical Considerations... 24
5. Findings ... 26
5.1 Bodily and emotional experiences of threatening situations: When do paramedics speak of threatening situations during work and how do they bodily and emotionally experience these situations? ... 26
5.1.1 ‘It is the uniform, it is okay’ ... 27
5.1.2 Lack of control ... 29
5.1.3 Getting physical ... 31
5.1.4 Emotions and bodily sensations ... 33
5.2 How do paramedics keep control over themselves in threatening situations? ... 35
5.2.1 ‘Switching, switching, switching’ ... 36
5.2.2 Emotion work ... 40
5.2.3 Professional feeling rules ... 44
5.3 How do paramedics keep control over the other actors in threatening situations? ... 47
5.3.1 Impression management ... 47
5.3.2 Interaction script... 50
6. Conclusion and Discussion ... 53
Bibliography ... 57
Acknowledgements
First of all, I would like to thank all of my respondents for making time for me and telling me openly and enthusiastically about their paramedic experiences. This thesis would not have been possible without their help. In particular, I would like to thank the two paramedics who invited me to join them on a shift to show me the real ambulance world. It was an awesome and very interesting day and we had lots of fun. Secondly, I would like to thank my supervisor Don Weenink for his critical assessment and helpful and inspiring advice throughout this last half year. Furthermore, I would like to thank Marit, my master-thesis-writing-library-companion, for all the complaining ánd motivating library breaks in the sun and where she - mostly - could encourage me to stay a little bit longer behind my computer. Lastly, I would like to thank my family and friends for their support and welcome distractions.
Abstract
This research is about paramedical personnel, healthcare professionals who respond to calls for medical help outside of a hospital, and their bodily and emotional experiences of tense and threatening situations during their work. It gives an idea of when paramedics think they have to emotionally deal with threatening situations during work and how they try to de-escalate. This is a qualitative research consisting of eleven in-depth interviews with thirteen paramedics from different places in The Netherlands who experienced threatening situations during work themselves. Based on the findings, this study suggests that the requirement of emotional labour and emotion work for the paramedic’s’ medical job is of great effect on their experiences of threatening situations as well.
1. Introduction
Aggression towards paramedics is a hot topic in Dutch media. Especially after last New Years’ Eve there were quite some headlines in the newspapers like ‘New Years’ Eve becomes a tradition of violence’ (NOS, 2019) and ‘President Mark Rutte wants to personally beat up the rioters’ (NRC, 2019). Therefore, people are aware of the fact that paramedics, like other (emergency) workers with a public task, have to deal with aggression and threatening situations during work. To show this in numbers, in 2015 65% of the Dutch ambulance personnel had to handle aggression of third parties during their work (van Zwieten, 2016, p.14).
Although the violent situations shown in the media are incidental, the national and regional ambulance and other paramedical organizations are serious about this issue. They prepare their staff with special training and courses and are actively trying to get their personnel make official reports about ‘workplace violence’, so they can get a better insight into what is happening during work. Still, after reading the paper on violence of the
Ambulancezorg Nederland (AZN) and having spoken to a few paramedical care staff
members, the fact remains that only a small part of the paramedical employees will file an official report of aggressive situations (Brandsma, 2016). Most of the time they will only mention a situation where physical violence was used, while in a great deal of the situations verbal violence and aggressive gestures are expressed towards the paramedical personnel, which remain unreported (Idem.; van der Velden, 2015; Cenk, 2019). Also, I think the term ‘workplace violence’ suggests that there needs to be violence involved for these types of situations, but there is more than that which can be threatening during work and which should possibly be reported or must be heard.
Note that I do not want to pretend that paramedics regularly have to deal with threatening situations and that the sensational news in de media about their job is all that there is to say about their field. The paramedics definitely do not experience threatening situations on a daily basis1 and it frustrates them that the media makes it look like they do
experience it often. One of the reasons I was interested in their experience with threatening situations, was because of the requirement of performing emotional labour in their job. Paramedics need to be able to manage all kinds of emotions of different actors and themselves. And this was something I found interesting in combination with their experience and behaviour in threatening situations during work. Therefore, I wanted to interview them,
focusing on their experiences to find out how they handle it, instead of for instance reporting how often they have to deal with it or what kind of other people are involved in these situations.
There has been a lot of quantitative research done in this field, but not so much qualitative. Most of the quantitative research kept a certain distance to the paramedical employees themselves and only gave them pre-given and standardized concepts and definitions to use. Take for instance the longitudinal study on ‘Predictors of workplace violence among ambulance personnel’ (van der Velden, 2015). In this research, the ambulance personnel had to fill in a survey on how often they had to deal with physical aggression, serious threat, verbal aggression and being on guard (Idem.). To me, these terms seem too vague since everyone can interpret and experience these concepts differently. The analysis on ‘The exposure to violence and burnout levels of ambulance staff’ in Turkey gives a more detailed description of the forms of abuse (Cenk, 2019). With the verbal violence type ranging from swearing to verbal sexual violence and the physical assault type ranging from punching to throwing objects (Idem.). Still, this survey started out from formal definitions and the respondents could not give their own descriptions. Especially when doing research on bodily and emotional experiences, it is important to allow respondents to choose their own words and give their own definitions, so that the phenomenon itself can be investigated properly from an insiders’ lived experience. The categories that were given in these examples may not capture the lived experiences of the ambulance personnel themselves. This means that there is a risk that the researcher forces the categories upon the experience of the personnel and this is a validity problem.
Not only quantitative researches have these problems, but also some of the qualitative studies on ‘workplace violence’ are using pre-given definitions. Even though these studies draw upon in-depth interviews existing of open-ended questions, they are still using a pre-given definition of the concept of ‘workplace violence’ (Hassankhani et.al., 2017, p.20; Heckemann et.al., 2017; Fahy and Moran, 2018, p.245; Ward, 2019, p.3). By doing this, the researcher can still force the prior definition upon the lived experiences of the respondents. Although I will not use a pre-given definition like these qualitative studies and let the concept open for the respondents’ interpretation, these studies’ prior definitions did show me that ‘workplace violence’ can be used in a very broad way. Reading these studies helped me to see that there are multiple appearances of violence and that this should be clear for my respondents. So, I will widen the term of ‘workplace violence’ more to the term ‘threatening
threatening can for instance also be verbal or psychological manipulative. Thus, I will use a less standardized approach and will study this phenomenon from up-close, by using the definitions of the ambulance personnel themselves.
With this qualitative approach, I hope to give a comprehensive answer to the main research question: “How do paramedics deal with threatening situations?” With the following sub-questions I hope to make this main question researchable:
1) Bodily and emotional experiences of threatening situations: When do paramedics speak of threatening situations during work and how do they bodily and emotionally experience these situations?
2) How do paramedics keep control over themselves in threatening situations? 3) How do paramedics keep control over the other actors in threatening situations?
2. Theoretical Framework
I am going to use the following main concepts to guide the analysis of the fieldwork data. First, I will introduce two concepts of Goffman, face-work and impression management, to provide a better understanding of the interactions of paramedics with the public and how they express themselves towards them. After that, I will explain some important concepts of Hochschild to understand the emotions of paramedics. Then, I will discuss Katz’s idea of ‘falling out of the landscape’. After discussing these different concepts separately, I aim to integrate them to show how they can be used together to study the experiences of paramedics in threatening situations.
2.1 Face-work
In his study On Face-work Erving Goffman states that every person lives in a world of social encounters (Goffman, 1967, p.5). These are contacts with other participants either face-to-face or in mediated form. Goffman coins two important terms that are helpful to understand these contacts. The first one is a “line”. This is ‘a pattern of verbal and nonverbal acts by which he (sic) expresses his view of the situation and through this his evaluation of the participants, especially himself’ (Idem.). Also when the person did not consciously intend to take a line, the other participants will get a particular impression of this person, where he or she has to deal with.
The second term is “face”. This is ‘the positive social value a person effectively claims for himself (sic) by the line others assume he has taken during a particular contact. Face is an image of self, delineated in terms of approved social attributes (…)’ (Idem). It is important to look at face from a group perspective since the face of one person and the face of the others are constructs of the same order. The constructs are based on the social interaction between multiple persons. Furthermore, the situation also determines the operation of face (Idem., p.6). And finally, to maintain face in a particular activity, a person has to know his or her place in the social world beyond it (Idem., p.7). When persons feel they are in face, they will respond with confidence, security and assurance (Idem., p.8). Paramedics will probably feel they are in face when they have control over the situation and can perform their tasks properly. Once they take on a particular self-image which they express trough face, they will be expected to take the responsibility to live up to this expression and show self-respect. Maintaining of the resulting “expressive order” can result
when they notice they lived up to the expectations of the others and did a good job. Besides all of this, it is important to note that although face can be someone’s most personal possession and the key factor for feelings of security and pleasure, it can only exist in a societal perspective. Goffman says the following about this: ‘Approved attributes and their relation to face make of every man his own jailer; this is a fundamental social constraint even though each man may like his cell’ (Idem., p.10).
There are situations where someone does not achieve face. When a person is “in wrong face”, ‘information is brought forth in some way about his (sic) social worth which cannot be integrated, even with effort, into the line that is being sustained for him’ (Idem., p.8). Or a person can be “out of face”, ‘when he (sic) participates in a contact with others without having ready a line of the kind participants in such situations are expected to take’ (Idem.). In these cases, the image of the self can be threatened and a person is likely to feel inferior, embarrassed and confused. The person may become “shamefaced” and has “lost face” (Idem., p.8-9). “Face-work” itself means ‘to designate the actions taken by a person to make whatever he is doing consistent with face. Face-work serves to counteract “incidents” – that is, events whose effective symbolic implications threaten face’ (Idem. p.12). It is imaginable that paramedics have to deal a lot with face-work in tense and threatening situations. Paramedics have an important public role and have to do their work out in the open, where their “face” can be easily threatened by bystanders or even the victims. If they “lose face” or are “out of face” this can have a huge impact on the situation, because of the often emotional and uncertain scenes where they are expected to take the lead and control, as they are the professionals.
The person can try to “save one’s face”, which is the process of a person giving the impression to others of not having lost face. You can also “give face” when you arrange a better line for another person and in that way the person can gain face. As a member of a group, a person is expected to have a standard of considerateness, to save and accept the feelings and face of other participants. This standard of considerateness, a protective orientation, and the already mentioned above self-respect, a defensive orientation, make together a kind of mutual acceptance. Goffman says that this is a basic structural feature of interaction (Idem., p. 10-14). As paramedics always work in pairs, they are probably trained in saving and giving face to their colleagues in difficult situations. They need to have their lines prepared in order to keep or regain control over the situation and to be in face.
2.2 Impression management
Goffman’s notion of impression management relates to how people, in this case the paramedics, try to appear (Goffman, 1959). This concept is also of relevance for this research. Impression management can be a conscious or subconscious process in which the ‘performers’ try to influence the perceptions of other people. They can hide the backstage, where performers behave out of character and where suppressed feelings can be released that resulted from performances on the frontstage (Idem., p.114-116). This influencing of perceptions can be done by controlling the information in social interaction (Idem., p.204). The performers must act with expressive responsibility in order to not destroy the image of themselves or their own team and by this create embarrassment. This means performers should not display ‘unmeant gestures’ or other inappropriate intentional verbal statements or nonverbal acts (Idem., p.203). When an incident occurs, and the interaction leads to ‘a scene’, the reality of the performers becomes threatened (Idem. p.206). The attributes and practices to save a performance are loyalty (sustaining the line that is taken), discipline (management of face and voice) and circumspection (prudence) (Idem., p.207-213).
In medical situations paramedics need to control the information they give off in social interactions; they have to act with expressive responsibility. This is probably not only the case in medical situations, but in threatening situations as well or even more so, since they still need to be able to continue their job and above all need to give the impression that they are able to do so. Otherwise, they will signal that they are out of face and this can produce escalation in these already tense situations.
2.3 Emotion work and emotional labour
Partly inspired by Goffman’s take on face-work and impression management is the work of Arlie Hochschild. I will use her article Emotion Work, Feeling Rules, and Social Structure to give a better understanding of emotion-management (Hochschild, 1979). Hochschild elaborates Goffman’s idea of managing outer expressions, by also looking at actively managing inner feelings. She says that Goffman only looked at the direct management of behavioural expression or how people try to appear to feel, and did not give any attention to the management of feelings from which expression can follow (Idem., p.557-558). While we often work on inducing or inhibiting feelings to make them appropriate to a situation. We are socialized individuals who try to fit in situations and for this have to hold on to conventions
of feeling. Individuals are considered to have the capacity to control and manipulate emotions (Idem., p.552).
The activity of trying to change an emotion or feeling, in this case the effort and not the outcome, is called by Hochschild “emotion work”. ‘We can speak, then, of two broad types of emotion work: evocation, in which the cognitive focus is on a desired feeling which is initially absent, and suppression, in which the cognitive focus is on an undesired feeling which is initially present’ (Idem., p.561). Changing the emotions or feelings can be done in three different ways and these three can go together in practice. The first one is cognitive, which is about changing images, ideas or thoughts in order to change the associated feelings. Secondly bodily, changing physical symptoms of emotion. And the third one is expressive, the attempt to change expressive gestures in order to change inner feelings (Idem., p.562).
Another important concept of Hochschild’s theory is “feeling rules”. These are seen as ‘social guidelines that direct how we want to try to feel’ (Idem., p.563). People are not always consciously aware of these rules, only when they are confronted with specific questions about their mood or feelings in a specific situation. Often, a discrepancy arises between what we can expect to feel in a certain situation and what we should feel in that certain situation or as part of a particular social group. Hochschild summarizes these corresponding concepts clearly: ‘It is left for motivation (“what I want to feel”) to mediate between feeling rule (“what I should feel”) and emotion work (“what I try to feel”)’ (Idem., p.565).
Furthermore, there are two modes of emotion work: surface acting and deep acting. In the former, people hide or disguise what they are actually feeling and pretend to feel something else. Deep acting goes one step further, this is when people are actually altering what they feel (Shilling, 2012, p.124). This can be more dangerous because ‘of the self-induced feeling in deep acting, there is a risk of bypassing actual emotional experiences’ (Keesman & Weenink, 2018, p.4).
When experiencing tense and threatening situations during work, paramedics are possibly often confronted with the discrepancy between what they want to feel, should feel and try to feel. With emotion work, they might have to deal with surface acting or maybe even deep acting. Especially considering the professional role they perform and the way outsiders see them. Also, dealing with tense and threatening situations is not considered their primary task so it is actually not part of their job. Still, they do need to manage their emotions in these kinds of situations in order to perform their paramedical tasks and manage their own personal and private emotions and feelings as well.
Whereas paramedics in tense or threatening situations probably have to deal with emotion work, during their ‘normal’ professional activities they already have to put up with emotional labour, which is emotion work as a requirement for their job. ‘(…) the term
emotional labour should be used only in occupational contexts where one is managing
emotions (of others) because it is part of what the job requires. When performing emotional labour, individuals generally must conform to the expectations outlined by the employer. (…) the process of emotional labour is rooted in the personal interactions that are seen to facilitate the effective and smooth operation of an organization’ (Erickson, 2008, p.707). Emotional labour can also be achieved through what Hochschild calls surface acting and deep acting (Theodosius, 2006, p.896). By this, they are able to display socially desirable emotions. ‘This labour requires one to induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others’ (Hochschild, 1983, p.7).
Managing emotions is a big part of paramedic practice. The paramedics are frequently exposed to a lot of human emotions that are connected to pain, suffering, trauma, and death. So, they do not only have to manage their own emotions, but also those of the patients, families and possible bystanders. Research on health care shows that emotional labour is very complex and difficult and requires interpersonal skills. Also, the feelings and emotions of the professionals are genuine and need to be processed by them after the work undertaken (Williams, 2012, p.369). To manage their own and others’ emotions, paramedics acknowledged the importance of distancing themselves emotionally from the patient. This generally allows them to cope (Idem., p.370). Other strategies that are used to deal with emotional labour are for instance talking it through and ‘offloading it’ with work colleagues and partners and close family. Humour can also help to express and offload the emotions, which makes it a positive coping strategy (Williams, 2013).
2.4 Falling out of the landscape
The work on emotions by Jack Katz will be used to get a better understanding of the phenomena of “falling out of the landscape” (Katz, 1999, p.312-332). In this case, the “landscape” is a way to describe a social form of being in the world, like being a paramedic. In normal situations, people will have a somewhat neutral feeling and can navigate steadily in their social life. But when they lose this ability to navigate social life because they are interrupted by overwhelming bodily arousals, for instance in tense and threatening situations, they are falling out of this landscape and they will get a temporary sense of directionlessness.
All of a sudden they are thrown out of the taken for granted nature of daily life and this will be sensed in their body (Weenink et.al., 2018). There can be different ways of responding to this fall, like crying, getting angry, laughing at yourself or being ashamed and stunned (Idem.). These emotional responses reveal to the others something that was previously hidden from them and brings the expressive behaviour from the background to the foreground (Katz, 1999, p.312).
The question is if paramedics also experience this falling out of the landscape, because of the fact that coping with aggression and violence is not considered their primary task. And if they do, (how) are they able to stay focused on their job? At the same time, as mentioned in the introduction, only a few of the tense and threatening situations are being reported. So could it be that paramedics do not (consciously) experience the falling out of the landscape?
2.5 Resume: integrating the theoretical concepts
Now the theories have been made clear, the concepts can be integrated since they all work out together nicely. Already stated earlier, paramedics have an important public and professional role to fulfil. They always have to do their job out in the open in public spaces and due to their uniforms and cars they are very recognizable, which is of course necessary. But this also means that other people expect that they take the lead in emergencies and have control in the often emotional and uncertain situations. They have to be able to manage their own and everyone else’s emotions, otherwise panic and chaos might arise. This is part of the emotional labour of a paramedic and to show this they have to manage a certain impression. It can actually be dangerous if their performance gets threatened and they cannot control the information in de social interaction. This might negatively influence their medical procedures. The emotions of the victims and by-standers might rise very high and it might create a scene that can possibly escalate. The performance of a paramedic can be threatened and they lose or are out of face. For instance, the victims and by-standers will not listen to what the paramedics say and because of this they do not have control over the situation. Or when there are expressions of aggression towards the paramedics it is imaginable that their self will be threatened. In these cases, the line of acts of the paramedics, in which they have to control the situation and most of all give care to the victim, gets not approved in a positive way by the others. Because of this, face-work is needed to make their face consistent again with their line. Because paramedics always work in pairs it will probably be useful if they
know how to see if their colleague is out of face and how to give face to regain control over the social interaction again. For this, it could be useful for them to also be aware of their own (expressed) emotions and bodily reactions.
When looking at face-work and impression management, how people try to appear to feel and manage their outer expressions, it is also important to look at the management of inner feelings. In any way, paramedics have to deal with emotion work, since they are always involved in emergencies and highly emotional situations. But this is something they choose for and get prepared for because of the requirement of emotional labour for this job. On the other hand, dealing with aggression and threatening interactions is not their primary task, and although paramedics nowadays also get trained for dealing with this, it is still not their field of interest. So, it is understandable that when tension arises because of threatening behaviour of by-standers or victims, physiological arousal can be on a high level and paramedics can possibly be overwhelmed by emotions. To act effectively in violent confrontations can be very hard and control over their own tension and fear is needed. These overwhelming bodily arousals can also lead to the phenomena of falling out of the landscape. Their landscape of being a paramedic gets interrupted, their line and face are disconnected, and the feeling of being directionless will be sensed in their body. Coping with aggression is not part of a paramedic’s landscape or line and so in threatening situations their body and emotions can respond in an unknown and uncomfortable way.
It can be extra uncomfortable when falling out of the landscape arises while being a paramedic, because of the professional and public role they have. Being in this role and having to keep in mind the professional feeling rules, they cannot always show their inner emotions and due to this they might lose control over the situation. They probably have to deal a lot with feeling rules and emotion work to have control over what they should feel and try to feel in threatening situations, which can be conducted via surface acting and deep acting.
3. Methodology
3.1 Data collection
The data presented in this research were gathered during a period of less than two months. I started with the interviews at the beginning of April 2019 and had my last talk with a paramedic around mid-May 2019. The fieldwork involved eleven in-depth interviews, individual and in pairs, with thirteen different paramedics, as well as observational participation (ride-along). I also included two personal letters of two attacked paramedics, which they had written for their lawsuit, in the analysis. All the names of the respondents are fictitious and names of cities, regions, hospitals, organizations, and other businesses are not mentioned to protect the anonymity of the respondents.
3.1.1 Interviews
All of the interviews were conducted individually, except for two. One of the duo-interviews was set up like that because the two paramedics had experienced an attack together. During the interview, they could complement each other and it was interesting to see that they had different experiences after the attack happened. They said this was due to the difference in the number of years they worked as a paramedic and overall life experience. The other duo-interview occurred accidentally. It did not come across as if they had to hold back or could not be completely honest and open because of the other’s presence. All of the thirteen respondents allowed me to tape-record the interviews, so I could transcribe it afterwards. The interviews were usually held at the ambulance posts and a few times at a café or at people’s homes. For all the interviews I used the same topic list2. In many cases, I did not need to ask
these questions as respondents answered them by just talking and sharing their experiences.
In these cases, the interviews were more like conversations and only sometimes I had to give it more a certain direction (also to avoid talking for hours about various interesting parts of their job). Therefore, the interviews were relatively easy to conduct and gave me a good opportunity to stay close to the expressions and words chosen by the paramedics themselves. A few of the interviews were a bit more difficult. Some respondents found it harder to come up with their own examples, gave very short answers or simply just did not know what to answer. As I listened to these interviews during transcribing, I noticed that I kept on asking questions during these conversations and at times tended to suggest answers, which was exactly what I aimed to avoid in this research. So, as I analysed and coded the transcripts, I kept this bias in mind and excluded quotes that may have been overly triggered by my questions.
During the interviews, all paramedics were asked about what they think is threatening during work and if they could describe one or more examples of threatening situations. To get deeper into an experience where they still had a vivid memory of, I asked them whether they could provide more details of the way they felt emotionally and bodily in that situation and if they were, despite these perhaps intense and overwhelming emotions and bodily sensations, still able to do their job the way they wanted it to be done. Because paramedics always work in pairs, we also spend a great deal talking about how they could notice from each other that they felt threatened and how they helped each other and if they were trained and prepared for this. We also talked about how they managed and attempted to de-escalate these situations and how they think other paramedics but also the patients and bystanders expected them to react in threatening situations and if they were aware of this.
3.1.2 Observational participation
As I spent some time at the ambulance posts before or after the interviews, I was able to observe the workspace of paramedics. At every post, there is a kind of living room where they start their shifts, relax when they do not need to go somewhere during their shifts and ‘have a coffee and a talk’. When I would visit a respondent at the post I always got introduced to everyone who was there at that moment and a few times I was even offered a complete tour through the building, the dressing rooms and the ambulance cars. Sometimes I also had to wait a little bit till a respondent was done with some work before the interview or for instance till someone could bring me to the train station with the ambulance when their shift started. These moments of waiting were perfect to get a first impression of the ambiance
at an ambulance post and how paramedics interacted with their colleagues. They all seemed to know each other very well and were continuously making jokes about each other and were having a laugh. I could already tell that humour is very important here and a lot of their interaction is based on this. Also, I noticed that the ambulance world is quite a masculine world too. For instance, paramedics would tell tough stories about experiences during work. Although they like to make a fool out of each other, it appeared to me that they were like a family, something a few of my respondents later would say explicitly, and that they would always support each other.
For me, the moment that I could join an evening shift was the best part of my fieldwork. From three p.m. till eleven p.m. I could drive along with the two paramedics who invited me for this shift. I even got to wear an official ambulance uniform, so a few times when we got a call and came to help the people, they thought I was a paramedic as well. Besides that it was a very fun and exciting day for me, it was really helpful and enriching for this research as well. As I got a better understanding of how a shift would look like, what paramedics exactly do and how they interact with each other, but also with their patients and families and bystanders. Here as well I noticed the importance of humour. Not only between each other, as we were making jokes the whole time, but also in the interaction with the patients and the bystanders. They told me that first, of course, they have to feel what kind of situation they got into, but most of the time it is appropriate to make some jokes. Mostly, the patients and bystanders actually appreciate this, because it makes the situation lighter and easier to handle. This was also very noticeable during the ride-along, in all of the cases the communication was friendly and the jokes made the patients and bystanders feel comfortable. In the Findings section, I will explain a bit more about the use of humour being an important part of their emotion work. Of course, there is also the possibility that the situation is sensed wrong and not everyone appreciates these jokes. I did not encounter these situations myself during the ride-along, but the paramedics did experience this before.
During the shift, we got a lot of rides and were quite busy and I also noticed the importance of the ability to adjust very quickly to every new situation with different people and emotions. While the control room provides the paramedics with a short description of the situation, they still have to adjust and understand the situation really fast to be able to manage everyone’s emotions so they can do their job properly. For instance, we went from a not so heavy scooter accident with a woman with a brain concussion to whom we could tell jokes, to an emotional brother and sister whose eighty-eight-year-old mother was about to die. I
personally found this a little bit sad and difficult. But for the two paramedics, this was just usual stuff and nothing really heavy.
3.1.3 Private note of respondent
From the two paramedics I got to spent the evening shift with, I received their defence letters which they had written in response to a very threatening situation they had experienced together, whereby they got attacked by a relative of the patient they were taking care of. At the ambulance they have a BOT-Team3, a specialized team that helps the paramedics after
they experienced a traumatic event. For instance a resuscitation of a child or a young person, but certainly also after threatening situations they will give the paramedics a call. In this case, the BOT-Team told them to write up their experiences, which was later on also useful for their lawsuit. They told me that it helped them a lot with expressing their emotions and to clarify what exactly had happened. Reading the letters, I could also notice this and I think this data is of great value for this research because the letters were written only a short time after the incident. So, the memories and emotions were still fresh and the words are personally intimate. The letters offer an honest and realistic look at the consequences of a threatening incident like this on a paramedic.
3.2 Sampling
I used two criteria to recruit respondents. First, they had to work as a paramedic, thus responding to calls for medical help outside of a hospital, either at the ambulance or at a first aid organization. And second, they had to have experienced something during work that they found threatening and were willing to talk to me about. Getting in contact with possible respondents was not that easy as I had thought beforehand. From my personal network I got a few contacts; I hoped to find some more via snowballing, but this did not work out that easily. Some paramedics had not experienced anything really threatening or were still in training and some of them were abroad and were not available for being interviewed in the assigned period. Although I preferred to work bottom-up, I knew I had to find paramedics via a top-down approach as well. So, I contacted all of the regional ambulance organizations, but only a few of them responded positively. They would show my request to their employees, so they could decide whether they wanted to take part in the research or not. In this way, I got a couple of respondents for interviews and also a great opportunity to join the evening shift. All
the other organizations I had sent e-mails to, indicated that they did not want to participate. They did not want to let their employees decide themselves, because they were either too busy, or they did not want their staff to talk about this subject. They said that their paramedics are ‘proud’ of their job and do not want to be ‘portrayed’ like this. Although I was a bit upset by all the negative responses I got, I also could understand where they were coming from. In the media, there are so many negative stories about paramedics being attacked. It sounds like it happens all the time, but of course, that is not true. I hoped that they would understand that it was certainly not my intention to make this research a sensational piece like how it is described in the media, but I think they get so often requests looking like mine, that they just did not want to get involved in advance. And I just had to deal with that.
I got hope again when I spoke to someone from the ambulance organization in a particular city, who really thought my research could be of good help in their organization. He would talk with the managers and thought he could arrange some interviews. But after two weeks I got the message that the managers did not agree. They never gave a reason and the man I spoke to was very upset about it but of course, it was not his fault. My hope for, say, five new respondents in this city was gone and now I realized I really had to step up my game. So I just asked everyone I spoke to that week and I put the request for paramedics on all of my social media. Luckily I got some new contacts out of this and also by the time I started interviewing I could fix a few new respondents at the ambulance posts. In the end, I think I got a varied sample of paramedics from different places in the Netherlands. Respondents also vary in gender4, age, years of experience5 and type of place they work6.
These features might have affected my sample and thus the possible variety of meanings that respondents gave about their experiences. Furthermore, respondents held various positions; the role of the nurse is a bit different than the role of the driver, so this can also influence the way someone feels and acts in threatening situations. The nurse has to focus almost completely on the patient(s), whereas the driver can have more control over the relatives and
4 With most of the respondents I discussed whether their gender influenced their experiences. They all agreed
that it probably did. Generally, men attract aggression quicker than women, and at the same time are men often more (bodily) dominant when it comes to de-escalation.
5 From the interviews it became clear that work (and life) experience is an important factor for paramedics in
dealing with threatening situations. The more experience they had, the easier these situations could be dealt with.
6 Multiple respondents told me there is a difference in working in the ‘Randstad’ and outside of the Randstad.
There would be more aggression and violence in the Randstad, so I wanted to speak people from both places to see whether that really makes a difference. My interpretation is that verbal aggression probably happens more often in the Randstad, but the ‘intensity’ of the aggression or violence is not necessarily bounded to the place.
bystanders and the overall situation. Table 1 presents a quick overview of the interviews and respondents.
3.3 Data analysis
I tried to transcribe the interviews as soon as possible after the actual interview because in that way I could remember their physical gestures and the ambiance during the interviews the best. The transcribing was time-consuming, but it surely helped me to get really close the things they said and wanted to express (Bryman, 2012, p.482). I produced a word-for-word replica of the interview, including pauses, speech fillers, laughter, and verbal gestures, because all of these can communicate meaning and understanding (Hennink, 2011, p.211). Especially pauses and laughter I could use in my analysis to get a good interpretation of the answers of the respondents. Pauses would, for instance, indicate seriousness or difficultness, and laughter nervousness or sarcasm.
When the transcripts were done, I filed them in ATLAS.ti to analyse. Because I sometimes had a few days between the interviews, I already started with the analysis of the first interviews, before talking with the respondents that would come later. This means that between the collection and analysis of the data was a repetitive interplay (Bryman, 2012, p.566). Reflecting on my data while using ATLAS.ti made me able to focus my questions even better for the second half of my interviews. For instance, I would use different words to ask about particular topics and I would ask for more experiences and examples since I noticed that those stories provided useful data.
The analysing process in ATLAS.ti involved a combination of deductive and inductive coding. For the deductive coding, I used codes based on the theories used for this research. Because most of my interview questions were based on and derived from these theories by operationalization, this was quite easy to do (Hennink, 2011, p.218). I used codes as emotion work, emotional labour, face-work, falling out of the landscape, (professional and general) feeling rules, impression management, surface acting, emotional and bodily effects, and workplace violence. All these theoretical terms appeared in the data. Eventually, concerning the latter code, in the interviews I did not use the words ‘workplace violence’, but asked them when they think a situation is threatening during work. With this, I wanted to not put the focus on ‘violence’, but make it broader. Something threatening does not necessarily have to be (verbally or physically) violent.
Next to these deductive codes, I used a lot more inductive codes. These were new codes that emerged during the analysing process, which gave me a good insight into the issues that were raised by the respondents, since these codes almost all derived from the original words of themselves. This is of great importance for the research and allowed the data to “speak for itself” (Idem.). A few examples of inductive codes were control, de-escalating, humour, switching, social skills, uniform/personal, expectations, and aggression from family, patient or bystanders. These inductive codes are relevant for my purpose since they give meaning to the theoretical concepts and show how they are interpreted by the paramedics. These codes also gave me a better understanding of the similarities and differences between the respondents. Especially these similarities gave me the confirmation that the validity of this research would be satisfactory. The respondents reported similar themes and ideas and this made me believe that there is the possibility that they (almost) all have a common way to give meaning to what they experienced.
3.4 Limitations
Because I went for an intensive and qualitative study, I have high gains in validity. ‘The means of measurement were accurate and actually measuring what they were intended to measure’ (Golafshani, 2003, p.599). Because of this, the quality and trustworthiness are satisfactory. However, at the same time I lack high gains in reliability, which comprises whether the result is replicable (Idem., p.598). This is not merely because I could only interview a certain amount of paramedics in the time I got for doing the fieldwork, but I also think the people who agreed upon doing an interview were also a particular kind of group. I felt they found it rather easy to talk about this subject, perhaps because they volunteered for the study. So, the sample might be biased, missing out paramedics who did find it uncomfortable or confronting to talk about their experiences. It might be the case that their experiences with threatening situations are different than what I heard during the interviews. It is something I will never really know, but because of this, I could not include the “complete” paramedic world (although I tried in terms of gender, experience, position, and place).
Beforehand, I also had the idea of making use of video elicitation during the interviews. My idea was to watch a video about paramedics in threatening situations together with the respondents and in this way I hoped to get closer to their experiences because the video would make it more tangible for them and easier to talk about what happened to them. Unfortunately, I could hardly find any good videos of paramedics in threatening situations or
aggression towards paramedic personnel. The only ones I could find were clearly staged. My last option was to ask my respondents if they had sufficient video material of those types of situations, but the ones that I asked for it, did not have it. Therefore, I could not make use of video elicitation. I cannot say if it would have made a big difference in the end, but perhaps it would have brought an extra layer to the study.
Furthermore, all the interviews that I did were in Dutch. Because this thesis is written in English I had to translate the Dutch quotes of the respondents. Unfortunately, this translating-process also means that particular words and sayings of the respondents got lost or changed. In most cases, I added a footnote with the original Dutch translation. However, I am very aware of the fact that these translations are not exactly the same as the respondents said it. I hope my translations are still able to properly transfer their expressions and opinions to stay as close to their words as my primary intention was.
At last, using interview data, of course, has its implications, since participants will be discussing their experiences in a retroactive way. They experienced their threatening situations between weeks and years ago, so I could not gather these emotional reflections right after the incidents happened. For some of them, it was so long ago that it did not really bother them anymore and others had already talked extensively about it with colleagues or partners. (But still, they remembered these situations pretty well, so it must have made a reasonable impression). An alternative option to get at their emotional reflections closer after the incident would be to ask them to do audio diaries, where the paramedics can record themselves right after a threatening situation during work. However, for this method I would probably need way more time and very committed and consistent respondents. For future research this would be a good option for a new method.
Table 1 List of Respondents
Interview Who (pseudonym) Where Experience (years) Position 1 Jacob (M) Events/outside of Randstad 4 First aid/driver
2 Kees (M) Events/Randstad 30 First aid/nurse
3 Mandy (F) Outside of Randstad 12 (+ hospital) driver
4 Dennis (M) Outside of Randstad 8 driver
5 b Aron (M) Outside of Randstad 5 driver
6 Karen (F) Randstad 1 (+10 hospital) nurse
7 Bob (M) Randstad 10 driver
8 Freek (M) Randstad 17 (+23
hospital)
nurse
9 Sam (M) Randstad 2,5 driver
10 a Paula (F) Randstad 10 nurse
10 b Harry (M) Randstad 27,5 driver
11 Joep (M) Randstad 6 nurse
4. Ethical Considerations
Already at the starting phase of getting in contact with the paramedical organizations, I noticed the ethical considerations connected to my research. From multiple instances, I got the feedback that they did not want to let their employees talk too much about this subject outside of their work environment. When aggression occurred during their work, these organizations will provide them with support and I presume that these organizations are perhaps afraid that the interviews would be too difficult or painful. The organizations also see their employees as heroes who are proud of their job and they do not want that the topic of aggression and violence gets too much attention, as the media already devotes considerable attention to this issue. Even the contact who was very enthusiastic about this research could not convince his superiors to participate. I was not expecting that and I think it shows that this subject is quite sensitive. I presume that is has a lot to do with the media and the way they mostly give attention to the sensational, negative and ‘exciting’ violent stories about paramedics.
These responses of the contacted organizations made me become more careful in approaching new possible respondents. Of course, I did not want to come across as if I thought paramedics cannot cope with aggression or as if I wanted to write some sensational piece about violence acted against them. However, giving new contacts a better idea of the
content of my research, made me find more paramedics willing to participate in an interview and almost all of them were actually very interested in this research and found it a great topic.
All the respondents I interviewed have experienced tense and threatening situations during their work. Asking them about these moments can resurface negative emotions and it is important for me, as the interviewer, to respect their boundaries. I made the subject of my research very clear to all of them before we even made the agreement, so they knew about what we were going to have a conversation. The interview was not mandatory and they could reach out to me themselves if they wanted to participate. Therefore it was their own choice. Still, during the interviews expected or unexpected negative emotions and thoughts could be brought up and it was important to prepare myself for handling these emotions of the respondents and still be able to get the information needed to answer my research questions.
Sociologist Robert S. Weiss says the following about the responsibilities of the interviewer: ‘While interviews are extremely unlikely to introduce pain or trouble in respondents’ lives, they may well elicit in respondents an awareness of pain they had pushed out of their consciousness’ (Weiss, 2004, p.127). When a respondent gets flooded in emotions, the interviewer is not responsible for this and it should not change the relationship between the interviewer and the respondent. ‘It should have continued to be a partnership based on mutual respect, concerned with producing information useful to research’ (Idem.). To show respect for the emotions of the respondent, Weiss says this is expressed best by just sitting quietly. After this, the interviewer can say something that indicates understanding and ask if it is all right to go on with the questions. Sensitivity, tact, and respect for the respondent are most essential (Idem., p.127-128). When a certain topic or question is too hard to answer for the respondent, I could change the subject and try to return to the topic later on in the interview and attempt to approach the topic in a different way. Furthermore, it is very important to keep in mind that the interviewer is not a therapist or a friend, but it is a work and research relationship. For this I should convey a middle distance to the feelings of the respondent, be in touch and responsive to them, but certainly not overwhelmed by them (Idem., p.128). It is the researchers’ responsibility to be nonjudgmental and to not feel obligated to help respondents to understand themselves (Idem., p.131).
In the end, I do not think that my respondents had that expectation of the interviews and I did not encounter such moments as written above. I think they found it good to talk to someone outside of their work and family network, someone that listened carefully without judging or trying to give feedback. They made the choice themselves to share their
research on a topic that is serious for them. During the interviews my respondents did not have difficulties with telling their stories, there were no heavy emotions involved and they all told me their experiences because they wanted it to do that voluntary. I am sure I did not cross anyone’s boundary; they all seemed comfortable and we could have a laugh during the conversation. It is now my responsibility to make the most out of their information and to make their lessons known. ‘In any study we have an obligation to our sponsors, to our field, and to ourselves to produce the most useful report possible’ (Idem., p.131).
5. Findings
To be able to answer the main question “How do paramedics deal with threatening situations”, the first section of the findings will, first of all, describe when paramedics speak of threatening situations. Secondly, it will focus on the initial bodily and emotional experiences of paramedics of these situations. The second section of the findings will discuss how the paramedics cope with these initially experienced bodily sensations and related feelings. It will explain how they make use of emotion work and feeling rules in order to get control over themselves and, in this way, the situation. So to speak, this section will focus on the ‘inside’ experience of the paramedic. The third and last section will focus more on the ‘outside’ and the appearance the paramedics want to give in order to de-escalate and control a threatening situation and the other actors involved.
5.1 Bodily and emotional experiences of threatening situations: When do paramedics speak of threatening situations during work and how do they bodily and emotionally experience these situations?
5.1.1 ‘It is the uniform, it is okay’
First of all, what stood out in the interviews is the difference between threatening and aggressive behaviour by patients and bystanders directed to them as a paramedic or to them personally. Caught up in emotions and panic, people can be very angry or upset about the healthcare they received. Sometimes they think the healthcare came too late or was not good enough for instance. According to the paramedics, they do not agree with the protocol and express their anger towards the paramedics, who are often the first people in ‘uniform’ they get to see after calling the emergency number. In those cases, the paramedics usually can understand the anger and do not feel too offended, but still, some verbal assaults can feel threatening. Karen tells about a situation like this:
‘Once we drove into a street. It was in the evening so we could not see the numbers of the houses very well. (…) Someone walked by and tapped on the car window and asked where we needed to be. So my colleague said he could not tell him that because of privacy rules (…). But then the man got really angry and said “if you are here for my neighbour, I know where to find you, I will kill you!” something like that… (…) Well, that was a very strange answer! I was like huh?! So, we stayed in the car until he walked away and thought to maybe call the police but we didn’t. And you know, we understood, not that I approve of his behaviour, but we needed to be at his neighbour who had been very sick and had to undergo a lot of medical mistakes, not because of us but because of the hospital. And the whole neighbourhood had sympathy for them and then we came and were seen as those ‘caregivers’. So in a way, I could understand his anger.’ (Karen, 6)
Thus, they can understand the anger and aggression expressed towards their role as a paramedic. They are part of the healthcare system and people will look at them that way. When that system did something wrong in the eyes of the others, the paramedics are partly responsible as well. When the paramedics start their shift and step into their paramedical role, they are prepared for the kind of situations they can get into because of their job. They are trained for managing emergencies, awful medical scenarios and people who can get angry or upset about the medical procedures and are panicking because of the patients’ condition.7 As
soon as the paramedics take on their uniform they know that there is the possibility of having
to deal with this. They will have a “line” of acts to handle these situations, so their “face” will not be threatened (Goffman, 1967, p.5). The uniform allows them to transform into a kind of non-personalized and professional identity, which helps them to cope with these situations. Mandy makes this clear by telling that they will not recognize her anymore as soon as she is out of her uniform and in her personal identity:
‘When they express it towards the uniform, I don’t really have a problem with it, because you know, tomorrow they won’t even recognize me anymore. So it is not personal. It’s just because I’m the caregiver at that moment.’ (Mandy, 3)
The assault that Karen received in the first quote was getting more personal because the man threatened them by saying ‘I know where to find you’. Later on in the interview, Karen explains that when people clearly focus on her, by saying that something is her fault or that they know where to find her, it gets personal and threatening. Jacob agrees with this and gave this answer as his first reaction on what he thought are threatening situations:
‘When, and then I have to formulate this properly, when a person or a group orients their behaviour to you as a person. So then it has nothing to do anymore with the situation, because you can step out of that or you can react on that and say okay it is a ghastly situation but there is no aggression towards us. But the moment that that behaviour focusses on YOU as a PERSON, because when it is the uniform than you get trained for that and then you can think “Hey it is the uniform, it is all right.” But nowadays what you see is that often people address you as a person. And they will attack you as well. And I think that is very threatening. Absolutely.’ (Jacob, 1)
When people express their aggression towards the person instead of the role of the paramedic, the paramedic can feel like its face gets threatened. They can feel “out of face” because they will participate in a contact with others ‘without having ready a line of the kind participants in such situations are expected to take’ (Idem., p.8). It is not part of the social role they have taken on with putting on their uniforms, but it is directed to their personal role. The role they rather keep backstage instead of frontstage during their work; the role where suppressed feelings and expressions can make an appearance and where they behave out of character (Goffman, 1959, p.114). In this way, the paramedics cannot remain in their role and are left without proper lines of action. Often they will ask for the assistance of the police. The
police will continue the line of action and safe the paramedics’ face, so they can continue their medical tasks.
‘I think something is threatening when… when they [the patient and/or bystanders] threaten me with death or more in the sense of “I know where you live”. If they would threaten me in that way then uhhh, then I would file a report immediately. (…) The moment it [the threat] becomes too personal and I cannot do my job properly, then uhh I will call the police.’ (Sam, 9)
5.1.2 Lack of control
Not being in control was also frequently mentioned, sometimes in these exact words and sometimes more or less.
‘Ehh threatening… uh yes uhh when I do not have control over the situation anymore I feel threatened. When people are in panic they can come across quite aggressive, but I do not find that threatening. But uhh, but when I lose control over the situation, yes, then I feel threatened. (Sam, 9)
‘She [the patient] did not agree with our protocol. Uhm, and then her husband locked the door. And we were inside.. like, “first you are going to help us, otherwise you can’t go out”. And that is a form of aggression I think, not physical, but like psychological manipulation’. (Jacob, 1)
Besides, in a few of the interviews, I noticed that the respondent was scanning the environment or sitting on the side of the room or terrace with the best view on the situation. They said that being in control over a situation is now like their second nature. It is so important for their job, that when they are off duty they always want to keep an eye on their surroundings as well. Paula explains that she experienced a tense situation where she could not leave the room. After that, she became very aware that she always needs to have an exit. It happened in an apartment building where the mother was ill and her son, probably under the influence of alcohol or drugs, was very aggressive and was walking up and down the room. By doing this he blocked the front door, the only way out. After explaining to them what she was doing and how she wanted to help the woman, the son would not calm down and kept obstructing her way out.
‘And THAT I found threatening. I remember the driver said that he needed something, but he didn’t go to the car because he did not want to leave me alone in there. On the balcony or the gallery he called the control room like “we will not press the emergency button yet, but it is very tense here”. Yes, a really tense atmosphere. And I notice that I’m very conscious of that now. When I find myself in a certain setting. (…) that I am now aware of the fact that I leave the front door open so I can always leave. Or when it really does not feel right, I just don’t go in straight away. (…) Because yeah, I thought if he wants to do something to me now, I cannot escape and I have to jump out of the window and I will not survive that. So that was a real eye-opener.’ (Paula, 10a)
Lack of control can also mean that the emotions of the others involved are dominant, such as panic, frustration and feeling powerless. These emotions can be very compelling, which can also feel threatening because the paramedics cannot easily control these emotions. Most of the time, these dominant emotions are the result of conflicting expectations. The family of the patient feels powerless and is determined that their family member or whoever is needing the help gets it right away. But it regularly happens that the paramedic has another opinion about the procedure. These clashing expectations can bring up tense situations. People are caught up in their emotions and they can be hard to control for the paramedics. They can do or say unexpected things. Karen gave a suiting Dutch expression for this behaviour: ‘A cramped cat makes weird jumps’.8 And when the paramedic lacks control and
does not know when or if the other actor(s) will make a ‘weird jump’, it can feel threatening. Also, when people are under the influence of alcohol or drugs, their emotions can take over and can be very dominant as well. Of course, due to the emotional labour requirement of their job, paramedics are experts in managing other’s emotions. But when people are drunk or high, the respondents explained that there is nothing really they can do.
Dominant emotions of others can impede the paramedic’s work, which is also threatening according to a few of the respondents. Bystanders think they can help, but the paramedics usually do not need and want their help. The interference of others will only obstruct their job. Vincent and Aron tell me about this:
‘V: The intentions [of the bystanders] can be good but if you do not do what they want, they can get irritated and aggressive. So, when people already start being very compelling and trying to give their advice, we will be on our guards.
A: Yes absolutely. Like I already said, when they impede our normal medical activities and that can already be done with their compelling advice… On weekends with people partying, sometimes there are bystanders who say that they are also medically schooled or a doctor and then they want to interfere in your activities while they are also under the influence of alcohol or drugs. Well, this weekend I had a situation like that.
A: probably well-meant,
V: yes exactly, but it does impede your work, A: and it can turn into aggression,
V: yes because they keep on obtruding themselves to us and [when we do not want their help] then they do not feel heard by us.’ (Vincent & Aron, 5)
To make their medical procedures possible and to maintain a calm and clear situation it is important for them to keep control over the other actors involved. Otherwise, there will be miscommunication and this can easily turn into aggression, as Vincent and Aron explain in the above quote.
5.1.3 Getting physical
Almost all of the respondents agree that most verbal aggression is not that threatening. Often they can ‘understand’ it because the actors that are involved in the situation are very emotional and in panic or the patients have psychical problems for instance, which makes them say swear words they are not necessarily aware of. The respondents would not say that it is ‘part of the job’, but being called names happens more or less regularly and when it does, the paramedics will not give too much attention to it.
When there is physical aggression involved, all the respondents agree that that feels very threatening. Most of the time they can already sense that someone will probably get physical when a person gets too close to them. So, they always prefer to keep an armlength distance. But this is not always possible and in some cases physical violence cannot be avoided. It does not happen often, but still, a few of the respondents did experience physical aggression during work, while dealing with this is definitely not considered their task. Like Jacob, who was working at a three-day-festival and in the early morning had to check upon a guy who had been laying knock-out at his tent for the whole night. In the first instance, it did not really work out to wake him up, so while his colleague was getting a car to transport him to the first-aid post, Jacob tried it again himself:
‘Eventually, I noticed some kind of reaction in his eyes, so I keep yelling at him. “Wake up! Do you hear me?!” So he opens his eyes and he looks at me. And yes. I just… Normally I’m really alert, but I also just woke up and it was just stupid, but I was too close, my hands were down, and I was not prepared to defend myself in any kind of way, you know. So he opens his eyes and gets really aggressive right away. So he punches me fully right above my eye. Well, then he was awake! But I got a smack! So I proclaimed code red, that is the highest urgency for when there’s really something going on.’ (Jacob, 1)
In his case, the security at the festival came right away to help him and with ambulance personnel outside of events the police will come immediately when they press their emergency button, or the police are already on the spot if they think situations will get too chaotic or threatening. Thus, normally the police, and in this quote the security, will protect and look out for the paramedics so they can do their job. All the respondents said that they always have trust in the police. However, Vincent and Aron, unfortunately, had to experience a brutal physical attack where the police did not protect them as they should have done. They got attacked by a drunken family member of their patient in the narrow space of an elevator. Even though they made clear that they did not want him inside, the man managed to get in and got very physical. They got hit, kicked and even grabbed at their throat. For the paramedics, this was a very threatening situation and certainly, for a long time, it made them more on guard than before. Also, the first period after the incident they needed some time to process what they had experienced and Aron had to be off the ambulance for two weeks.
Physical violence is certainly not in line with the “face” and the social world of a paramedic. It is not their role to be dealing with this type of violence. It will probably easily threaten their face and they are likely to feel inferior, embarrassed and confused when dealing with physical aggression. This can even have a big impact on the (medical) situation since the paramedics are expected to take the lead and control but are probably less able to give a calm and controlled impression when being out of face. Also, because for most paramedics physical aggression is more emotionally and bodily overwhelming then other types of aggression, physical threats are more likely to invoke the sense of falling out of the landscape. The situations will probably feel even more threatening when they get this temporary sense of directionlessness.
5.1.4 Emotions and bodily sensations
The most common emotion the paramedics feel in threatening situations is anger. They come to help and not to get yelled at or receive any other type of aggression. That is certainly not part of their job. Jacob and Kees say:
‘As I said, I do get angry sometimes… because I think we’re not there to be taken the piss with. And I’m done with that stuff very quickly. First I would say a couple of times very directly like “okay till here and not any further, and listen to me now”. Uhm, but after a while I will be very done with it.’ (Jacob, 1)
‘Uhm, anger can be an emotion. Like come on, I am here for the patient, piss off because I cannot help him like this! That kind of anger. And because of incomprehension.’ (Kees, 2)
Although the respondents do get angry in some situations, they say they still have a certain amount of patience. Mandy explains:
‘Sometimes I can also get a little bit angry. Then I think like how can they [the aggressive people] do like that?! And other times I think like well, I can understand that you get mad, but it is like this right now. You can get mad later. But for now you just have to be patient.’ (Mandy, 3)
Mandy clearly does not like it when people get annoyed or aggressive, but often she can understand it and empathize with these people. That is something almost all of the respondents can do really well. Of course, when a situation gets physically violent it is more difficult, but in most cases the paramedics can understand the anger and aggression and can get rid of their own anger quickly in order to carry on with their job. It is an important part of their job to acknowledge those feelings of others and manage their own emotions as well. Because when they get angry, the others will probably get angrier and then it might escalate. And escalation is something they want to prevent at all times. Also, if the paramedics feel fear or anger and in the first instance they want to express this, they often cannot do this because they need to focus on helping the patient. They are expected to control the situation and show tranquillity and professionality. How they manage and cope with their initial emotions will be explained in the second chapter on emotion work and feeling rules.
