Adopting a ‘System of Caring' as a leadership strategy toward professionalisation within South African emergency medical services: A grounded theory

African Relevance

• •African EMS agencies are grappling with the process of professionalization, with one of the reasons being the ongoing negotiation and formation of professionalism as a meta-ethic within the EMS work systems. African EMS agencies are becoming far more aware of the impact of low staff morale and burnout within the EMS sector.
• •Research exploring the social interactions and process within African EMS is lacking, which serves as one of the barriers to understanding and developing robust EMS systems within the African setting. This research seeks to contribute to our understanding of how people are interacting as professionals within the African EMS sector and intends to contribute to assisting in the process of developing standards for professionalism as they relate to EMS system work ethic thus contributing to improving the resilence and sustainability of African EMS systems.

Abstract

Introduction: Professionalization is a key agenda within South African prehospital care. Emergency Medical Services (EMS) agencies continue to grapple with operationalising the process of professionalising, with a number approaches described in literature. This research presents a System of Caring developed within the context of EMS as an approach to achieving professionalization. Methods: A qualitative research design in the form of constructivist grounded theory design was used. Participants were enrolled using purposive and theoretical sampling. Data were analysed using coding procedures in a constant comparative analysis approach supported by theoretical sensitivity. Analytical diagrams consistent with grounded theory methodology were also employed, primarily in the form of inter-relational diagraphs. Results: Six main categories were established with associated coding lists. Coding lists were used to develop groups of propositions that were then abstracted to construct final analytical labels that captured the elements of the System of Caring. These elements include caring for the leaders, caring for the team, caring for the patient, caring for each other (collegial) and caring for self. The components of each element were also abstracted, and the System of Caring developed. Conclusion: While there are various well-established definitions for the term care, within the context of the perceptions of the participants of this study, care (and caring) means a combination of constructed environmental conditions and people-process practices that recognises the well-being of the people within the processes. This ‘System of Caring’ offers a practicable way to operationalise caring into the workforce and move toward exploring how to promote professionalism within the workforce, through a ‘System of Caring’. While this may have been reasonably extrapolated before, this research allows for a poignant insight into how EMS agencies can promote professionalization within EMS systems within South Africa, through the ‘System of Caring’.

Introduction

Problem formulation

Professionalising a country's Emergency Medical Services (EMS) toward being a self-regulating, self-governing and autonomous healthcare unit is not a novel or new idea, with efforts beginning over a decade ago within the United Kingdom healthcare system where significant patient safety incidents led to questions being raised regarding the effectiveness of ‘paternal governance and regulation’ of the EMS system by physician led initiatives [1,2]. Research focusing on African EMS systems has demonstrated a significant variance in the existence and function of EMS systems across the African continent [3,4]. This has highlighted the importance of supporting the ongoing development of African EMS systems, part of which includes the need for EMS agencies to pursue clinical independence through capacitating paramedics to become clinical leaders and steer clinical governance and leadership within the EMS agencies using appropriate competency frameworks [1], [2], [3], [4], [5].

Within the South African setting there have been a number of focused research initiatives aimed at improving pre-hospital care systems, however these initiatives have highlighted the need for further research into, and development of SA EMS systems and processes [6,7]. Mianda et al suggest there is an ongoing systemic lag in the development of clinical leadership competency among frontline healthcare providers, leading to slow professionalization of ‘non-physician’ based healthcare units [8]. While Mianda et al focused on nurses, these findings can be reasonably extrapolated into the EMS space given the relatability in their findings, similar findings of international literature and the lack of South African EMS specific research [8], [9], [10]. This is very concerning given how fundamental effective leadership is to promoting and sustaining good quality patient care and supporting a healthy, safe clinical working environment [8,11,12].

Professionalism within EMS encapsulates the operationalisation of promoting and sustaining good quality patient care and supporting a healthy and safe clinical working environment, which in turn relies on the animation of necessary values, beliefs and assumptions [13,14]. For this reason, professionalism can be viewed as the outward facing, tangible manifestation of an organisations work ethic, embedded within the organisational culture, and cultivated by the activities of the leadership (and leaders) within the given organisation [9,11,13,14]. Within the EMS setting, research has shown that paramedics will role model other paramedics that are respected and recognised for living the values and beliefs that are positively regarded within the given work systems, and that these role models will be sought after within the shared working environment [1,9,10,12,14,15]. Understanding the relationship between leadership, role modelling and professionalism is key to understanding the rationale behind the value and importance of a ‘System of Caring’ in connecting the various stakeholders within an EMS work system, to a shared set of values and beliefs that will then drive the work ethic, which is experienced as professionalism and measured as good quality care and a safe clinical working environment.

Multiple studies that investigate the idea of leadership indicate that further research is needed to better understand and appreciate the dimensions of this component of EMS [8,9,16,17]. It is generally accepted that the research currently available does not adequately explore the full nature of the interactions between EMS personnel and the aspects within the EMS environment, like leadership, ethics and the nature of work [8,11,16]. This research set out to explore and understand these interactions which led to the development of the ‘System of Caring’ as a response to the finding that experiencing caring within the EMS organisation supports professional practice, as an outcome of professionalism. Recognising this connection between a ‘System of Caring’ and the promotion and supporting of professionalization brings to the fore the importance of the reciprocity between effective leadership and a conducive organisational culture [9,11,13,14]. This research suggests that a conducive organisational culture should incorporate caring as a cornerstone value, and that this can be operationalised through the ‘System of Caring’

Within the SA EMS setting there is significant variability in organisational culture across the various private and public EMS agencies. While standards of professionalism have been articulated through various legislations, these documents primarily address endpoints or outcomes of professionalism, and are not a means to operationalise relevant values toward promoting and supporting professionalism and professional practices. One of the consequences of this void is the shifting of ethical frameworks, embodied in organisational cultures, toward practices that are objectively unethical, in response to contextual work system elements - the pervasive presence of the practice of financial medicine in its many forms is an example of this [18]. This sentiment of the existence of unethical organisational cultures within EMS agencies was echoed in the findings of this research.

Achieving professionalization of South African EMS, will primarily rely on effective and focused leadership and a subsequent shift of the organisational culture within a given EMS agency [1,8,9,[11], [12], [13]. Of significant importance is the causal relation that has been established between good leadership and change in organisational culture, with the link being that organisational culture change will be mediated by good leadership [8], [9], [10],12,19]. Furthermore, it is also important to understand that when talking about organisational culture the emphasis is on the practice of ethics - that is that the ethical culture is the organisational culture [13], [14], [15],20]. Operationalising this requires adopting a tangible work ethic that embodies the values that are regarded as being essential to being professional, of which one of these values that has been identified in this research is 'caring' in the work system, and which has been presented here as the ‘System of Caring’ [20,21]. Connected to this is the essential role that leadership structures play in communicating and mediating the flow of caring within the work system [9,13,21,22].

While the role and importance of organisational culture, ethical culture and leadership have been explored, the component of the individual's perception of these elements and how they relate and perceive that these elements contribute to being able to perform well at work is largely unexplored in the South African EMS setting [11,12,16]. The way that EMS leadership is understood and perceived is not known within a South African setting, as well as there being only a vague conceptualisation of how leadership is developed and what the ideal abilities and characteristics sought after in EMS leadership are [8,16]. Extending from this is a lack of understanding around how EMS agencies’ organisational cultures are operationalising or being experienced in the operationalisation of these organisational cultures by the workforce. The Authors have attempted to explore and understand some of these gaps, which subsequently has led to the development of the ‘System of Caring’.

The goal of professionalization within EMS is to achieve a state of effective and responsible self-regulation, self-governance and autonomy within all aspects of the EMS as a healthcare unit. This is reliant on a change in the organisational culture, which we propose can be mediated through the 'System of Caring' . Effective leadership is essential to promote and support the ‘System of Caring’, which when operationalised will modulate the organisational culture to create work system conditions conducive to the promotion and support of professionalization [1,8,9,[11], [12], [13].

Research question

One of the areas that has yet to be formally investigated within the South African EMS setting is the perception of prehospital EMS personnel regarding how ethical leadership is connected to doing good work. Embedded in this question are the additional questions of 1) How EMS personnel perceive ethical leadership and 2) How they perceive good work. The researchers set out to understand these perceptions, as well as to analyse and understand the interactions of these perceptions within the EMS work systems. The researchers used Howard Gardner's Theory of Good Work as a reference point for the conceptualisation of an objective sense of what would constitute Good Work. Gardner et al define Good Work as being “work that is of excellent technical quality, work that is ethically pursued and socially responsible, and work that is engaging, enjoyable and feels good” [21,23].

Using a grounded theory approach, the researchers were able to analyse and engage with the data to abstract and develop an understanding of the EMS workforce perceptions and how these perceptions impacted workforce performance. The Good Work theory assisted the researchers to understand and make sense of the findings within the context of social processes relating to ethical leadership and doing good work [21], [22], [23]. Through this process, the role of value and the action of valuing were identified as being underpinning qualities in the process of professionalization. This value flow network has been captured as a ‘System of Caring’ and offers a lever for engendering organisational culture shifts that then subsequently promote professionalization. In light of this, the researchers incorporated the theory of Creating Shared Value in order to appreciate what value, and the action of valuing objectively means within the context of work, professional activity and quality of life [24,25]. The theory of Creating Shared Value is described by Porter et al as “policies and operating practices that enhance the competitiveness of a company while simultaneously advancing the economic and social conditions in the communities in which it operates. Shared value creation focuses on identifying and expanding the connections between societal and economic progress”(24,25).

This paper proposes an EMS specific model for an organisational culture, in the form of a ‘System of Caring’, that supports the achievement of professionalization as a function of transmitting value through caring within the South African EMS work systems. This model was constructed using the results gained from investigating, exploring and contextualising how the EMS workforce are currently experiencing EMS leadership, the achievement of Good Work and EMS organisational culture in general.

Methods

Qualitative Approach and Research Paradigm

This research was conducted using a qualitative research design, in the form of a grounded theory approach, through the perspective of constructivist grounded theory, which has been selected as an appropriate design given the intention to research social interactions and processes [26]. Through engagement with the participants, constructivist grounded theory focuses on how the researcher works with the participants, as data sources, to construct meaning through the development of categories and theories [26,27].

Researcher Characteristics and Reflexivity

The primary researcher is an Emergency Care Practitioner (ECP) who has been working in South African EMS for over 10 years. An ECP holds a professional degree in emergency medical care and medical rescue, and functions as the top tier emergency care provider within the pre-hospital environment. During this time the researcher has worked in a number of different roles, across a variety of work systems and work units. These roles have included working as a junior ambulance volunteer, an undergraduate ECP student, an operational ECP, a Paramedic educator, a clinical mentor, and an aeromedical retrieval ECP. The primary researcher has worked in both the private and public EMS sectors, as well as within the higher education sector. These experiences inform the primary researcher's personal and technical perspectives, as well as enabling the primary researcher to invest significant subject matter knowledge and expertise into the data analysis procedure, which is instrumental in the constructivist grounded theory research approach [26,27].

Context

The research took place within the cities of Johannesburg and Mogale, involving Emergency Medical Services (EMS) members that voluntarily consented to participate. Sampling was initially purposive, selecting individuals from diverse working environments. However, as data analysis began the process of theoretical sampling was utilised in response to the findings drawn out through the constant comparative analysis process [26], [27], [28], [29], [30].

Sampling Strategy

Purposive sampling aiming for variation across private and public sector industry within different work area experiences was employed in order to initiate the sampling process, following which theoretical sampling was employed as informed by the ongoing data collection and comparative analysis process. A total of 10 participants were enrolled in the study [26], [27], [28], [29], [30]. Interviews were conducted until data saturation became evident, with data saturation being assessed in terms of theoretical saturation whereby the researcher was able to recognise saturation through the ongoing and iterative process of constant comparative analysis through sampling and coding, and recoding, of data sets until no new relevant variations of existing categories emerged [26,27,29].

Table 1 describes the characteristics of each participant that relate to purposive sampling. Work Areas pertain to the roles that have been held over the course of each participant's career. Work system indicates the kind of EMS agency that the participants have worked in. EMS- Emergency Management Services, BLS- Basic Life Support, ILS- Intermediate Life Support, ECP- Emergency Care Practitioner.

Table 1.

Sample Demographics.

Participant	Work Areas- Roles	Work System	Years of Experience
Participant 1	EMS Call taker EMS Despatcher Shift supervisor	Public EMS System	22 years
Participant 2	Operational Paramedic	Private EMS System	3 years
Participant 3	Operational Paramedic Remote Site Paramedic Retrieval Paramedic (ECP) Flight Paramedic (ECP)	Public EMS System Private EMS System Industrial and Remote site contracts	19 years
Participant 4	Event Standby Paramedic	Private and Corporate Event Medical Standby	3 years
Participant 5	Leading Fire Fighter Squad leader Ambulance officer-BLS Medic	Public EMS System	17 years
Participant 6	Ambulance officer- ILS Medic Shift supervisor	Public EMS System	5 years
Participant 7	Operational Paramedic (ECP)	Private EMS System	1 year
Participant 8	EMS Call taker EMS Despatcher Shift supervisor	Public EMS System	13 Years
Participant 9	Ambulance officer- ILS Medic	Private EMS System	9 years
Participant 10	District Manager Station Manager Shift Supervisor Operational Paramedic Leading Firefighter Ambulance Officer EMS Call taker EMS Despatcher	Public EMS System	19 years

Ethical issues pertaining to Human Subjects

The data collection methods and procedures were approved by a tertiary institution's research ethics committee. Written consent was obtained from each participant to participate in an interview and be audio recorded. Voluntary participation was supported through the use of an approved research information letter which was provided to the participants. All data was handled in a confidential manner, with assurance achieved through signing non-disclosure agreements. Data protection mechanisms were also employed throughout the research process, through encrypted files that were password protected.

Data Collection Methods

Data collection was initiated with the use of audio recorded one-on-one interviews, using a responsive interview protocol [26,27,29,30]. Three questions were used to open up the conversation, after which conversations evolved depending on what the participants shared. The three opening questions were ‘How is work going?’, ‘How has work been?’ and ‘What is happening at work these days?’ Participants were interviewed in a location of their choice, outside of their work environment and while off duty. Following on from this, memo writing was employed (concurrently with the interviewing process), which involved the researcher capturing observations, thoughts and reflections, which also served as a source of data [26,27]. Practically this was achieved by using iterative and inductive reasoning, while also maintaining (and applying) theoretical sensitivity throughout the data collection and analysis process [26,27,29,30].

Data Collection Instruments and Technologies

In the context of grounded theory methodology, a specific element contributing to the trustworthiness of the research process was the ongoing activity of memo writing which was used to capture the thoughts, feelings and intuitions of the researcher while serving as a record of how the analytical process evolved and led to theory development [26,27,29]. In essence the memo writing served as a primary source of data as well as the main source of the audit trail, which is a recognised measure to ensure trustworthiness [26,27].

Data Analysis

Audio recordings were transcribed and then subjected to coding procedures. Manual coding of the raw data occurred over three distinct phases of open coding, focused coding and theoretical coding following which the theorisation process took place [26], [27], [28], [29]. Procedurally this was undertaken in conjunction with the ongoing process of constant comparative data analysis [26,27,31]. The written memos were also subjected to constant comparative analysis as well as memo sorting procedures [26,27]. Using the coding lists, 6 groups of propositions were formulated in order to further develop and abstract the meaning of the processes and actions contained in the participants perceptions and experiences(26,27).

The process of proposition formulation involved reviewing the focused code list in conjunction with written memo's and raw data, so as to continue the comparative analysis procedure [26]. Once the proposition construction was complete, the final analytical labels were formulated to incisively and succinctly capture processes and actions pertaining to ethical leadership and good work in EMS [26]. The process was hermeneutical in nature with the procedure of constant comparative analysis helping enable the researchers to constantly interact with and question the data in the development of a theory that is grounded in the data and not merely a subject of preconceived hypothesis or propositions [26], [27], [28], [29], [30]. Analytical diagrams consistent with grounded theory methodology were also employed, primarily in the form of inter-relational diagraphs [26], [27], [28], [29].

Techniques to Enhance Trustworthiness

The precepts of dependability, credibility, confirmability and transferability were applied in order to ensure the trustworthiness of this study. This was achieved through various mechanisms of data triangulation according to well-established practices pertaining to each of the four precepts [26], [27], [28]. Some examples of these practices include interviews, field notes, member checking, memo writing, and observation for data saturation [32,33].

Table 2 demonstrates the practical steps that were taken by the researchers in order to ensure trustworthiness.

Table 2.

Measures of Trustworthiness.

Strategy	Criteria
Credibility	-Triangulation of data using in-depth, individual interviews, field notes and memo writing during data collection. -Member checking was promoted by encouraging participants to perform ongoing member verification and review raw data. -Independent, ongoing re-coding by a seasoned researcher was conducted during data analysis and incorporated into the constant comparative data analysis cycle to affirm the analysis made by the primary researcher. -An audit trail was composed by the researcher, consisting of the researcher's journaling, field notes and transcriptions -Ongoing Memo writing with ongoing constant comparative analysis was carried out by the researcher throughout the data collection and analysis phases.
Transferability	-The background information and contextual elements relevant to this study were explored and described in relation to emergency care personnel. -The applicable settings were provided and described in detail to promote an assessment of transferability of findings. -The method of sampling, data collection and analysis has been described in detail to promote reader evaluation for transferability of the research.
Dependability	-A detailed description of data gathering, analysis and interpretation was presented and referenced against accepted practices. -Triangulation using in-depth interviews, field notes and memo writing. -Independent re-coding by an outside source to confirm researcher findings took place. -Theoretical sampling was employed, relying on the researcher exercising appropriate theoretical sensitivity. -An audit trail composed of journaling, field notes and transcriptions were compiled and remains available for various levels of verification. -Ongoing Memo writing with ongoing constant comparative analysis was carried out by the researcher throughout the data collection and analysis phases.
Confirmability	-Triangulation of data using in-depth interviews, field notes and memo writing. -Member checking was conducted by encouraging participants to perform ongoing member verification and review raw data. -An audit trail composed of journaling, field notes and transcriptions were compiled and remains available for various levels of verification. -Ongoing Memo writing with ongoing constant comparative analysis was carried out by the researcher throughout the data collection and analysis phases.

Results

Links to empirical data and Formulation of a ‘System of Caring’

Through the data analysis process analytical labels were abstracted and grouped into categories. Ongoing comparative analysis was utilised to construct final category labels which captured the overarching process and related actions contained within each category. These labels were worded using gerunds to maintain the focus on processes and actions [26]. The 6 category labels are listed below with an accompanying direct quote.

• •
  Category 1- ‘Being a leader in EMS’

  ‘So, for me a good leader is someone who leads by example. You come to work on time, you spend time at work, then you address the problems that you have, you listen to people, you have meetings, you get to the bottom of what people need and what they want and I think if a leader doesn't come to work it is because they are avoiding the problems and it becomes worse and worse.’-Participant 3

• •
  Category 2- ‘Good-working in EMS’

  ‘Yes, because when people have a passion, they give more than 100% to what they're doing, they focus, they give their best, they treat the patient like I'll almost say like royalty. They respect the people. They do what they need to do the best they can...For me the difference was when I worked with somebody who had a passion for what we were doing. I would go home feeling satisfied for the day. I felt good because the day was used to do something for people that needed the work we do.’- Participant 4

• •
  Category 3- ‘EMS workforce are expecting’

  ‘So knowing very well that I had an ALS in my shift who is always ready and prepared… I know how passionate she is about her capabilities and her skills… Afterwards I was happy with her. I was very, very happy because I trusted her… she went beyond for the patient.’-Participant 6

• •
  Category 4- ‘Being in EMS’

  ‘We're like a family. If you're family you're very tight. You know each other, you can speak to each other if there's problems. The guys that don't – is not interested. They'd rather go on their own.’-Participant 5

• •
  Category 5- ‘Growing in EMS’

  ‘Then there's also mentoring people, when we manage patients together, because at the moment, the ALS is not appointed officially in a leadership role. So it's’ more of a mentoring process as the senior qualified person where you would on a patient call, explain things, show them how it's done, why do we do things’ Participant 3

• •
  Category 6- ‘Surviving in EMS’

  ‘In my opinion what I've experienced, that is what's happening. People don't do a proper job… Because they don't have self-respect, they don't respect other people, they don't have a pride in their job, they don't have values, norms and integrity.’-Participant 4.

The 6 category labels and associated analytical labels were then subjected to mapping using inter-relational diagraphs in order to understand the relationships between the described actions and processes within each category with a specific focus on identifying drivers and outcomes which made more explicit the interactions between the actions, process and people in the EMS work system. By using the inter-relational diagraphs and an understanding of how the categories were composed, thematic labels were developed to capture the link between people centred actions and process in relation to the activity of caring. This allowed for further organisation of analytical and category labels according to actions and processes within the work system, in relation to the process of communicating care. The use of this iterative approach, supported by the constant comparative analysis approach, resulted in the construction of the ‘System of Caring’ theory, which is grounded in the data [26,27,29]. This resulted in the development of the six thematic labels and associated category labels, which are shown in Table 3.

Table 3.

Thematic labels and associated Category labels.

Thematic Label	Associated Category Label
Caring for Self	Recognising Value/worth Having Satisfaction Having Happiness Growing through Work
Caring for each other/ colleagues	Understanding Hardships Sacrificing self for good of the Other Supporting through Suffering
Caring for Work	Excelling to be Better Committing to making it Work Having Integrity toward doing good work
Caring for Team	Protecting workforce dignity Recognising worth through pay Supporting Workforce Promoting Growth
Caring for Leaders	Supporting Efforts Accepting Decisions Recognising Efforts Respecting Authority
Caring for Patients	Being Willing to make Sacrifices Being Compassionate Valuing Recovery

Grounding thematic labels in the data for the construction of a ‘System of Caring’

While there are various well-established definitions for the term care, within the context of the perceptions of the participants of this study, care (and caring) means a combination of constructed environmental conditions and people-process practices that recognises the well-being of the people within the processes. In terms of the activity of caring, participants have located this activity in the processes of caring for the leaders, caring for the team, caring for the patient, caring for each other (collegial) and caring for self. This is demonstrated in Fig. 1. When exploring the experience of care and the way participants perceived the operationalisation of caring, the shared point of reference that appeared within all participants’ perceptions was one of value and being valued. This extended into value for the work done, value for the person doing the work and value for the purpose of (doing) the work. Moreover, value was communicated through the experience of care, and the experience of care appeared to motivate the willingness to care.

Fig. 1.

‘System of Caring’: EMS personnel perceive Good Work as work that is done with care, and EMS personnel perceive ethical leadership as leadership that is done with care, and EMS personnel perceive that the role of ethical leadership in doing good work is that of fostering, promoting and protecting a ‘System of Caring’ that permeates all aspects of the work done. A leadership that is genuinely caring for the workforce will drive the workforce toward caring about doing good work, as leadership acts as the mediating factor within the ‘System of Caring’. The role of leadership in modelling and promoting caring behaviour, through the example that they set, is regarded as essential to being effective leadership that will drive professionalization within an EMS system. This illustrates how using a ‘System of Caring’ as a leadership strategy will promote and support professionalization.

The mediating factor within the ‘System of Caring’ is the role of leadership in modelling professional behaviour and through the example that they set, embodying the values, beliefs and assumptions that are regarded as essential to being professional within an EMS system. Essentially, EMS workforce feel valued when they feel cared for, and apparently, they are able to perceive ‘caring’ in the work system when their own expectations of ‘being cared for’ are met. Similarly, the workforce is readily able to perceive a lack of care in the work system and often are able to locate where they believe the lack of care originates from. The findings of this research indicate that the EMS workforce believe that the lack of care originates from within leadership structures, and that this promotes an unethical work ethic within the given work system. Below are direct extracts from the interview transcripts that illustrate this;

‘I think most paramedics just sit in the response car, or find a recreation area to sit, but it's not their own space…I'm not sure what the thought process is behind that, whether it's logistics or finances, or whether they want people to not be comfortable or what the thought process is... You'd definitely be negative to come to work. So, if you were more comfortable, it gives the impression that your employer values you a bit more’-Participant 3

‘The officers at that time they were very strict. They were more disciplined … If an officer hasn't got pride in himself, why must the guys have pride. He must lead by example; he must be neatly dressed and everything. If he's not, the firefighters will follow. Why must I be neat but my officer can't be.’- Participant 5

‘I think they should develop the culture of setting examples. Whatever that they want to see happening they should actually do it first.’-Participant 6

‘How would I describe it? Carelessness, don't care attitude, no one takes responsibility so what. No one's going to punish me. That attitude, because when you report to the elder person, they just take that report and throw it away. You follow it up. You're getting tired as well. So that's why you feel like now, am I really needed here. Do I really need to be here? Don't care attitude. Even the managers, the commanders, they cover up for them mos.’-Participant 8

‘Even when I was at [redacted], they do, they take advantage of you, they say go do this call or you complain about the vehicle not being safe. For them as managers, being higher up as long as they're comfortable and happy they don't look down…like it's those where their company as itself doesn't care.’-Participant 9

‘This is also another thing from management. If my resource is running, I don't really care what's on it, as long as that resource is running and the complacency says I'm running ten ambulances in my area and I want ten ambulances on the road and I really don't care what they look like. Put me ten ambulances, then I can go do my next thing... Meanwhile there's a shortage of equipment or the staff are not interested etc. that's not my focus. My focus is on my ten ambulances.’- Participant 10

The findings of this research indicate that valuing the work being done is a key component of the workforce and requires clear alignment between purpose and outcome, seated in a sense of good performance and appropriate expectation within both the workforce and the work system. Apparently, the workforce's own perception of how well their productivity is being received and accepted is linked to the level of value being communicated to them while being productive as determined by subjective constructs of ‘being cared for’ at work. Below are direct extracts from the interview transcripts that illustrates this;

‘Management should be open to suggestions. And not just say no. I mean if I'm open to suggestions and say listen, what do you guys think we should do or shouldn't do…make them feel important, make the staff feel important, from management side.’-Participant 1

‘To actually give you some sort of recognition. Everything is self, you don't get a lot of recognition. Everyone is out to make it harder for you for no reason… But it starts at leadership and there's incidences where some paramedics would sit on someone's back…just to add that extra pressure.’-Participant 2

‘The other thing is it seems like they're not worried about us. They don't care. They don't care. It seems like they're not interested in seeing what's happening on station level. We're just there, we're just a number…A good leader of management, I'll say he should take some time and go and visit his stations. And start building up relationships… instead of being against them. Which is not happening.’-Participant 5

‘Like no one wants to hear your views. That's why I think it's kind of one sided and prejudiced because that's how things are. You can't really change it so it's kind of your fault that you are experiencing it…I just want to be acknowledged as a human. So inhumane maybe. That's better. Ja. We're just expected to be robots and we're not. When they take away all the human aspects that I'm saying. They're not caring because the manager's not caring, they just want the money which I don't think in this industry it shouldn't be like that.’-Participant 7

‘But I honestly think what's happened to the service is we've gone through this process where things have got worse and worse and worse. We're still doing the same job, we're still going out to save lives, we're still going out to treat the injured, we're still going out to rescue the people but we're not doing it brilliantly, we're doing it because we have to. - Participant 10

Synthesis and Interpretation

The concept of a good quality of life is deeply rooted in the concerns and values of the participants in this research. While subjective in experience, the perceptions among the participants are that work must contribute positively to their quality of life, and that this is experienced through being cared for at work. This appears to be at the root of the tension and dissatisfaction of the participants, as members of the EMS workforce, around the operationalisation and experience of a lack of caring within the work systems in EMS. Apparently participants demonstrated strong associations toward holding leadership and management in EMS responsible for how work impacts their experience of being cared for at work, which they attached to their quality of life at work. Participants seemed to measure this impact on their quality of life through the way that the systems and processes operationalised within the EMS work systems, and whether or not they felt cared for in the systems and processes.

These insights led to the development of the ‘System of Caring’ which has been mapped out in a diagrammatic format (Fig. 1). The mapping demonstrates the exchange of care between the various stakeholders within an EMS work system, demonstrating the interdependence of each stakeholder in the promotion and support of the flow of caring as a reciprocal exchange of the recognition of each stakeholder's value, through experiencing caring. This reciprocity of care is operationalised through specific actions and processes that are specific to each stakeholder and captured as the category labels under each thematic heading- essentially the category labels encompass actions and processes that will promote, communicate and support care. When reflecting on the actions and processes advocated the role of effective leadership becomes evident, with a mediating role becoming apparent in the role modelling and support of the actions and processes that communicate care, and thus in the promotion and support of caring in and of itself.

Discussion

Integration with prior work, implications, transferability and contribution to the field

The connection between workforce performance and expectations has been described in the literature, with extrapolated connections drawn into the EMS industry [13]. Similarly, the relationship between trust and professionalism as a social process has been well established and recognised as an essential antecedent to professionalism within the EMS setting [2,14,[34], [35], [36]. What is less clear is the connection between trust, expectations and the experience of ‘being cared for’ as an antecedent for professionalization from the point of view of the EMS workforce member. Considering available literature, the realisation that the South African EMS workforce seek out and desire an experience of caring in the work system is not unique to the findings of this research, with various international studies demonstrating that an ethos of caring is fundamental to effective EMS systems [2,14,37]. What has been lacking in the research is a means to actually operationalise an ethos of caring into an EMS work system, which the authors have attempted to address through the ‘System of Caring’.

However, locating the activity of caring in people-mediated processes is less well described in available literature, and indicates a valuable insight gleaned from this research. This insight into avenues of care recognised by the participants, as articulated in the ‘System of Caring’, is encouraging in so much as it demonstrates the propensity for the promotion and achievement of human flourishing, which we assert in the context of EMS is the achievement of professionalization. The concept of promoting and securing human flourishing within the setting for work and professional activity has been captured in a variety of business ethics theories such as the theories of Good Work and Creating Shared Value, which can similarly be readily applied to the South African EMS context [21,23,24,38].

The desire participants articulated in terms of being valued and cared for represents an authentic expression of the EMS workforce, and resonates with the realisation that EMS workforce identify with having an inviolable human dignity and a claim for the recognition of that human dignity through the activity of being valued and cared for within their given work system [38], [39], [40], [41]. This contextualises the findings of this research that EMS workforce look for and desire a ‘System of Caring’, demonstrating that authentically caring about the well-being of each stakeholder within the work system is a central activity to achieving professionalization within South African EMS, and that this is operationalised through communicating care which maximises the flow of value within an EMS work system [21,23,24,38,39].

When considering the perceptions shared by participants regarding work place value and care, the insights attained aligns well with the concept of having dignity in work and how the work a person does is a natural extension of that human person and their experience of human dignity [40,41]. A general product of pursuing professionalization is that of workplace value-satisfaction and workforce care, with value-satisfaction and comfort being specific indicators of attaining human flourishing, which in the contextually specific sense is a good quality of life enabled through professional participation in EMS [24,34,35,[42], [43], [44].

With regard to the association frequently apparent in the perceptions of the participants, between experiencing and witnessing care and how this motivates the provision of care, this observation resonates with the augmenting effect of community engagement on individual behaviour- a key consideration in the process of doing Good Work [35,45]. This is significant as the process of EMS workforce observing for, expecting and aiming to promote, communicate and support care within the EMS work system is well documented in various research studies [2,14,37]. What was not yet clear was how these desires, expectations and intentions could be practically operationalised, an outcome now tangible in the findings of this research and presented as the ‘System of Caring’.

Caring consistently comes through as an essential characteristic of being in the EMS workforce and directly related to the displayed notions of what is ‘good work’ [23]. It is definitely a multifaceted process, with care for the patient, care for the work and care for each other in the workforce featured as the prominent attributes, which have been explicated in the findings of this research and feature prominently in the ‘System of Caring’ [2,35,44]. In any instance, the perception that is most commonly held by the workforce when there is poor work performance or collegial relations breakdown, is that ‘they don't care’, with ‘they’ simply serving as a placeholder for whom ever is the subject of a given process. Captured in the ‘System of Caring’ is a clear reciprocity of care that relies on an exchange of care between individual stakeholders through specific actions and process that are perceived to communicate care- this drives the experience that ‘they do care’.

The implication is that caring is more of a background, general, passive attitude or approach to doing the job which seats squarely in how things get done and not so much in what things get done (allowing for some exceptions). The findings of this study indicate that as the workforce readily perceives a lack of care, their own work ethic is modulated which demonstrates an important link between perceiving care (or no care) and the embodied work ethic, which directly impacts the achievement of professionalization as product of good work. Extending from this is the EMS workforce expectation that EMS leadership role model, promote and support the actions and processes that are perceived to communicate care, and so in doing show that they recognise the value and worth of members of the EMS workforce.

Such realisations have not gone unnoticed within the EMS fraternity. However, the connection between caring and value are not as succinctly articulated in terms of human dignity, with the general treatment of this concept relegated to the process of professional conduct in so much as it relates to providing patient care and maintaining collegial engagement during the work process [2,20,[34], [35], [36],44]. Such a treatment results in care and professionalism being understood as outcomes or measurable behaviours, whereas the ‘System of Caring’ offers a practical means to actually develop and attain professionalism. Through implementing the ‘System of Caring’ as a leadership strategy, and EMS agency has a practical way to promote and support the process of professionsalistion. Furthermore, the actions and processes that need to be promoted and supported to communicate represent intervention points for leadership structures to induce an organisational culture shift that embodies caring as a cornerstone of the work ethic that will the drive the doing of ‘good work’ which is made manifest in professionalism.

Within published literature there is a general awareness of the role that caring as a value has in professionalism and professionalization, however the conceptualisation that the activity of caring between and among the workforce is connected to responding to the needs of the workforce to be valued and recognised is not apparent. The ‘System of Caring’ as a leadership strategy addresses this gap, providing a practical means through which care, and thus value, can be communicated within a work system and adopted as means to promote and support EMS professionalization. Literature has pointed out that caring is crucial to professionalism and professionalization, but it has not yet established how this should take place in respect to the wider social activity of the EMS industry, and does not seem to elucidate why caring as a process can be connected to recognising a person's value and dignity [2,11,20,35,44]. The ‘System of Caring’ seeks to address this and provide a practical means through which caring can be communicated within an EMS work system and thus creates a conducive environment for an organisational culture that embodies a work ethic which promotes and supports professionalization.

Limitations

The sample population were drawn from a specific geographical area. Similar studies conducted in multiple other geographical areas may prove to strengthen the findings of this research or offer new insights. The sampling strategy used does not allow for deliberate heterogeneity, this may be a sampling weakness, however the authors assert that the sampling strategy used is appropriate for the research design used and consistent with the constructivist grounded theory approach, which promotes the trustworthiness of this data.

Conclusion

The findings of this research are useful as the grounded theory of a ‘System of Caring’ a practicable way as a leadership strategy to operationalise caring within and into the workforce and, thus move toward promoting and supporting the ongoing professionalization of EMS agencies. The findings of this research suggest that EMS personnel perceive Good Work as work that is done with care, and EMS personnel perceive ethical leadership as leadership that is done with care, and EMS personnel perceive that the role of ethical leadership in doing good work is that of fostering, promoting and protecting a ‘system of caring’ that permeates all aspects of the work done. A leadership that is genuinely caring for the workforce will drive the workforce toward caring about doing good work. These findings show how implementing a ‘System of Caring’ can serve as a leadership strategy toward promoting and supporting professionalization in EMS.

Dissemination of Results

The original thesis, from which this publication was drawn, has been made available on request to the study participants. A copy of the thesis has been placed in the academic library at St Augustine College of South Africa. The authors intend to publish these results (as a series of articles) in free to access journals (hence the application to AFJEM).

Authors Contribution

Authors contributed as follow to the conception or design of the work; the acquisition, analysis, or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content: CGM 80% and JPK 20% All authors approved the version to be published and agreed to be accountable for all aspects of the work.

Declaration of Competing Interest

The authors declare no conflict of interest