The paramedic experience of return to clinical practice: A reflexive thematic analysis

Abstract

Background: The Australian paramedic workforce has significantly expanded and evolved in the past few decades. Professionalisation, increasing demand and evolving clinical practice have contributed to pressure on paramedics to meet community expectations of service delivery. Returning to clinical practice after an absence presents a substantial challenge for paramedics who will need to navigate this transitional phase while readjusting to the fast-paced environment of pre-hospital care. This study aims to explore and understand the experience of paramedics returning to clinical practice. Methods: Paramedics were invited to discuss their experiences returning to clinical practice in ambulance services within Australia. A qualitative reflexive thematic analysis was conducted utilising an inductive approach, underpinned by the theoretical framework of the organisational support theory. An experiential orientation was supported by a critical realist ontology, which intersected and overlapped with epistemological contextualism. Results: Three major themes were identified: (1) perceived organisational support, (2) the reality of flexible work, and (3) clinician identity. Theme one was further broken down into three sub-themes relating to structure, work engagement, and clinical support. Conclusions: Our findings provide insight into the lived experiences of paramedics returning to clinical practice. These experiences and challenges should inform the application of organisational policy and resource allocation to better support returning paramedics in the future. Strategies should include enhanced leadership capability, flexible work, robust clinical education, and structured programmes with in-built flexibility to reintegrate staff with an emphasis on communication and support.

Keywords

return to work paramedics paramedicine qualitative work engagement

Introduction

Increasing demands on the global health sector are driving the need for a fully functioning and flexible health workforce. In the wake of the COVID-19 pandemic, the health workforce has undergone significant change with a shift in focus to sustainability into the future.¹ Investment in flexibility will enable health organisations to capitalise on the existing workforce, such as professionals wishing to return to clinical practice. Absence from clinical practice occurs for a variety of reasons including, parental leave, carer responsibilities, research, career progression, personal health, discipline or career dissatisfaction.^2,3 Return to clinical practice and workforce reintegration after a career break can be daunting for health professionals.⁴ The terms return to work (RTW) and return to clinical practice (RTCP) are used interchangeably however, RTCP is used here to emphasise the unique challenges and responsibilities that fall upon healthcare professionals when returning. Barriers to successful return to work have previously been identified and associated with childcare, occupational stress, reduction in clinical confidence, skills degradation, and lack of organisational support and flexibility.^2,5,6 Numerous insights have been gained from previous research exploring RTCP in healthcare professionals, however, this has yet to be explored within paramedicine.

The role of a paramedic has undergone significant change and evolution over the past two decades in Australia. As a result, defining paramedicine has become problematic due to the profession's identity evolving and diversifying.⁷ Service delivery now involves the provision of pre-hospital emergent and non-emergent healthcare to the community, often in uncontrolled and unpredictable environments.⁸ The majority of Australia's paramedic workforce are employed by large state-wide ambulance services that have tiered clinical systems and scopes of practice ranging from basic life-support providers to critical care response.^9,10 Most are ‘advanced life support paramedics’ whose scope of practice sits in the middle of the range, with their wages and benefits comparable to other health professionals in Australia.¹¹

Recent professionalisation of paramedicine in Australia has seen increased responsibility, higher expectations and robust regulation in a largely autonomous role.^12,13 Paramedic RTCP has been a contemporary and evolving concept since the introduction of registration with requirements for recency of practice.¹⁴ In acknowledgement of growing demand, several re-entry to practice university-based programmes have been developed to satisfy registration requirements and provide support for returning paramedics.^15,16 The combination of practitioner autonomy and complex job demands, within a unique and dynamic environment can create a challenging work experience.¹⁷ Returning paramedics will be required to overcome these challenges in addition to navigating flexible rostering within a 24-hour rotating shift model, supervisor engagement and clinical education to facilitate their RTCP. Nursing literature heavily features supervisory support and preceptorship to mitigate these problems, however, this may be impractical to generalise to the field of paramedicine where independent practice and single-officer response are not uncommon.^6,18 Despite this evolution, there is currently no literature or research to support or understand the experiences of paramedics returning to clinical practice.

The prevalence and extent of paramedics returning to practice as a problem is largely unknown however, what is known, is that paramedicine has a high incidence of work-related musculoskeletal and psychological injury.^19,20 A recent quantitative study exploring RTW outcomes found that paramedics with psychological injury had a reported high rate of return at 68.8%, although the mean lost time was 269.7 days which is significant.²¹ Notwithstanding this, assumptions can be made that paramedicine can expect increasing numbers of RTCP obligations. The greatest share of the Australian health workforce are females aged between 20 and 34, which is consistent with paramedicine trends.^22,23 Women are twice as likely as men to require part-time employment, largely due to childcare and caring responsibilities.²⁴ Research on nursing attrition in return to practice students also cited childcare as the most prevalent reason to undertake RTCP.²⁵ The literature for paramedicine is scant, although a previous study in the United States explored attrition and RTW intention in the emergency medical services and found that the majority of the participants left because of a desire for better pay and benefits, which encompasses childcare and parental leave and interestingly, 72% reported that they intend to return to practice.²⁶

Looking toward a future of fair culture and inclusive practice emphasising the psychosocial safety of paramedics, ambulance services may find value in an increased focus and investment in RTCP to help inform organisational policy and future direction. In this context, this study sets out to explore and understand the experiences of paramedics returning to clinical practice. This research expresses particular interest in exploring truths of the participants’ experience and how they made sense of their involvement, with an aim to identify any patterns of shared meaning of their behaviour, perspective and perceived organisational support.

Methods

Qualitative approach and research paradigm

Reflexive thematic analysis (TA) as described by Braun and Clarke²⁷ was the chosen method for our study due to its theoretical flexibility. Our intention was to explore the phenomenological aspects of the lived experience, including the connection to the social context in which the participants were situated. The exploration aimed to identify any patterns of shared meaning among the group, therefore reflexive TA was considered a suitable approach.²⁸ Following this conceptualisation, the authors made a series of conscious decisions to build the underpinning ‘methodology’ and frameworks in which the research would be conducted under the umbrella of reflexive TA. These decisions were made with the research question, aims and researchers’ subjectivity in mind.

An empathic and experiential orientation to the research was applied to utilise participant subjectivity as a resource, where participants were treated as the experts of their own experience and language was seen as a reflection of the contextually situated reality of truth.²⁹ This orientation was underpinned by a critical realist ontological position, which assumes that a reality exists independent of our beliefs and constructs and posits there is no possibility of knowledge production that is independent of all perspectives.³⁰ Critical realism theories intersect and overlap with epistemological frameworks and contextualism, whereby knowledge production is provisional, and can be shaped by researcher interpretation, or by our social, individual, or theoretical lens.²⁸ In the context of this research, this epistemological stance coupled with critical realism allowed researchers to not only understand the paramedics’ experience of returning but also to acknowledge the context in which they live and work and how this may have influenced the participants’ perspective, choices and sense-making of their experience.

Researcher characteristics and reflexivity

The research team members are all registered paramedics, with varying levels of experience and expertise to contribute to the project. The lead researcher is an advanced care paramedic, experienced in supervisory roles and currently pursuing a Master's degree in paramedicine. The research assistant is a critical care paramedic gaining insight into academia, and the team is supervised by a professor of paramedicine and academic leader in the field. All researchers were cognisant of critically reflecting on the content and context of the knowledge we produced and how our subjectivity shaped the analysis and interpretation. Reflexivity was a new concept for the lead researcher to grasp, therefore guidance was sought to appreciate the significance of intertwined personal, interpersonal, methodological and contextual factors in reflexivity and how to address them.³¹

The team was positioned as outsiders to the research in varying degrees. The lead researcher has not experienced a return to clinical practice, however, has been involved in managing and facilitating programmes for other paramedics, which additionally provides an insider perspective. This involvement has contributed to formulating assumptions and opinions, which ultimately led to this research being conducted. This subjectivity has been embraced and acknowledged at various points in the research as this provided an understanding of current systems and programmes in which the participants were situated. The lead researcher kept a written reflexive journal throughout the research project, commencing from project conceptualisation. The team's overall knowledge, experience and reflexivity shaped the research to broaden our scope and ensure our interpretation was relevant and trustworthy and positively contributed to the current body of literature in paramedicine.

Participant setting

Registered paramedics from any service in Australia who had returned to clinical practice were eligible for inclusion in the study. It is important to note that RTCP programmes are individualised and vary across regions. As such, the setting varied depending on the participant's location and which phase of the programme they were in at the time of the interview.

Participant recruitment and selection

Participants were recruited using a purposive sampling strategy where paramedics known to have returned to clinical practice were emailed from distribution lists after having completed an RTCP programme. Snowballing techniques were encouraged to identify further eligible participants using social media. The national recruitment strategy aimed to achieve rich descriptions and diverse perspectives within the population, with the aim of creating transferable findings.³² Due to this research being the first in its field, there were no restrictions placed on RTCP parameters, such as the reason for time away, length of time away, or programme requirements. This was intentional to maintain a broad scope to explore and understand all RTCP experiences in the first instance.

Differing viewpoints to data saturation were considered, and a sample small enough to immerse in the data and large enough to provide rich and meaningful understanding was settled upon with acknowledgement that this number is subjective and was largely influenced by our time and resource constraints.³³ Once we felt we had achieved a balance between the pragmatic (time/resources) and the theoretical (richness of information) priorities, recruitment ceased. This sample size determination was chosen to avoid refinement of the coding process which may occur with traditional ‘saturation’ models which carry underlying assumptions that the data become redundant after a certain point.³⁴

Data collection

Data were collected using in-depth, semi-structured interviews, to provide an opportunity for the researcher to be spontaneously responsive to explore the story of the participant's experience.²⁸ Interview prompts were used as a guide to standardise questioning across participants, see Supplemental Appendix 1. The interviews lasted between 16 and 45 minutes and were conducted using videoconferencing software Zoom, due to the geographical distance the research spread across. Zoom is a suitable and cost-effective qualitative data collection tool, which allows researchers to observe participants to pick up on non-verbal cues to assist interpretation of meaning within context.³⁵ Interviews were audio- and video-recorded, and transcription was auto-generated within the Zoom software. Initial transcripts were reviewed as an iterative process to ensure rich data were being elicited, and subsequent adjustments were made to the questions following this. The review process also allowed pause for interpersonal reflexivity; some participants were known to the interviewer in a professional capacity, we understand this relationship could impact or influence the data collected and mitigated this by acknowledging the potential power gradient and explicitly informing the participants of the separation between this research and our organisation. Transcripts were provided to participants for reflection to offer additional insight, as opposed to traditional verification or member checking.³⁶ Data collection occurred throughout September 2023.

Data processing and analysis

Braun and Clarke's most recent iteration of reflexive TA was used to guide data processing and analysis.³⁷ The six phases of analytic engagement are outlined in Table 1. Data analysis utilised an inductive approach, meaning the analysis and exploration were driven by the data rather than deducted from an existing theory.³⁷ This inductive approach was then underpinned by theoretically informed assumptions in the context of organisational support theory.³⁸ This theory posits that employees perceive the organisation as a living being with purpose and intention, and perceived organisational support is optimised when principles of employee attribution, social exchange and self-enhancement are applied.³⁸ The researchers considered this to deeply intertwine with the individual experience of returning to clinical practice, socially located within the organisational context. This theoretical positioning encouraged further engagement and attention to detail with the data throughout the entire process. Authors were sensitive to the possibility of this delimiting the analytic process by narrowing the field of vision, at the expense of other important aspects as cautioned by Braun and Clarke.²⁷

Table 1.

Thematic analysis and author engagement based on Braun and Clarke’s procedures.³⁷

Phase	Author engagement with the process
Phase 1: Data familiarisation	JO – Listening and re-listening to interview recordings whilst editing transcription errors. Transcripts were de-identified and participants were allocated numbered pseudonyms, e.g. Paramedic1, Paramedic2, etc.
Phase 2: Coding	JO – Data immersion and analysis continued as an iterative process to generate codes at a semantic and latent level, using NVivo software.³⁹
Phase 3: Generating initial themes	JO – Codes were collated to develop initial theme generation using both NVivo software and manual sorting methods.
Phase 4: Reviewing and developing themes	JO – Themes were reviewed and further developed which involved reconsideration of all codes, and coding clusters. Full review of the dataset to ensure correct context was applied.
Phase 5: Refining, defining and naming themes	JO, AR and BW – All authors were involved to ensure methodological coherence and reflexivity. The intention here was not to reach consensus on data analysis, but to ensure a critical openness and interrogation of the data using reflexive practice. Themes were defined and explained, with considerations for the flow of information.
Phase 6: Producing the report	JO, AR and BW – Analytic excerpts placed together with consideration of overall narrative – authors reviewed final piece for story coherence.

Trustworthiness and rigour

Guidance from Elliott et al.⁴⁰ was used to address trustworthiness and rigour at multiple stages throughout the research paper. This study adheres to the Standards for Reporting Qualitative Research (SRQR) reporting guidelines.⁴¹

Ethics statement

Ethical approval was granted by the Monash University Human Research Ethics Committee, Project ID 38331. All participants provided informed and signed consent.

Results

A total of 13 interviews were conducted, lasting between 16 and 45 minutes with a mean of 27 minutes. Participants were representative of two states in Australia and had a variety of reasons for time off and a diverse range of experiences. In some instances, participants had completed multiple RTCP programmes and were able to compare each experience. It was anticipated that parental leave would be the most common reason for time off, this was consistent with our findings which included 15 instances of maternity leave and 11 instances of other circumstances. Characteristics of the participants can be seen in Table 2.

Table 2.

Return to clinical practice participant characteristics.

		Total
Participants	In-person interview	1
Participants	Virtual interview	12
Gender	Female	11
Gender	Male	2
Service	Organisation 1	10
Service	Organisation 2	3
Skill set	Advanced Care Paramedic	10
Skill set	Advanced Life Support Paramedic	3
Years of service	<5 years	0
	5–10 years	4
	10–20 years	7
	>20 years	2
Reason for time off^a	Maternity leave	15
	Injury or illness	5
	Travel	2
	Higher duties secondment	3
	Career change	1
Number of RTCPs	1	4
	2	5
	3	4
Length of time off^a	<12 months	6
	12–18 months	14
	2–5 years	4
	>5 years	2

Instances of multiple returns included in figures. RTCP: return to clinical practice.

Data interpretation led to the generation of three major themes: (1) perceived organisational support, (2) the reality of flexible work and (3) clinician identity. Theme one was further broken down into three sub-themes relating to structure, work engagement and clinical support.

Theme 1: Perceived organisational support

This theme highlights the importance of perceived organisational support and its flow-on effects on staff contributions and psychosocial wellbeing. Three sub-themes were created to demonstrate various ways of conveying, or not conveying support, which together shape employees’ perception of organisational support which impacts their overall experience of return to clinical practice.

Structure

The participants shared a common desire for a structured RTCP programme. They consistently expressed the idea that having a clear plan and direction would provide them with a sense of support and guidance. Though some didn’t articulate what the structure should entail, or why it was necessary, they frequently alluded to the intersecting notion that structure equals support.

So that all felt very clear. I had a nice list. I knew what I was going in to do for the day, so that all felt quite, you know, clear, direct and supported in that. – Paramedic 2

The structured programmes were associated with perceived support, whereas a disorganised or ‘casual’ approach made participants question whether they were an inconvenience or burden to the facilitator. This perception led them to wonder if the organisation valued their contributions.

I guess if the return to work isn't structured, I feel like it's just like a, a little bit of an inconvenience. – Paramedic 1

And I was like actually does anybody have any awareness of what's happening with me. Does anyone even care what's happening? … But it'd be nice not to be feeling like a burden. – Paramedic 11

Several references acknowledged the existence of policies and procedures that guided the RTCP programme. These guidelines were described as ambiguous, inconsistent and subjective which led to frustration in the group. Participants reported they believed genuine attempts had been made to develop the guidelines to provide a consistent and fair approach. This sentiment and doubt led researchers to believe it ultimately failed to meet expectations. Many attempted to make sense of the phenomenon by questioning roles and responsibilities and providing excuses for the failures, such as uninspiring management, lack of awareness, and geographical challenges. Perhaps the need for structure emerges from the inconsistent application of the guidelines or policies that are widely known to exist.

I feel like a return to work, like it needs to be really, like structured and I'm sure that this structure actually exists but I've just I don't know, people just don't seem to abide by it or like that. Yeah, (maybe) I just had a bad manager at the time or whatever. – Paramedic 4

Individualised programmes and flexibility within the structure were found to be crucial. There was an emphasis on the importance of a standardised approach that allows for individual needs, where a ‘one size fits all’ should be considered the minimum standard. Proposed solutions included a structured programme that conducts training needs analysis to inform the individualised curriculum.

I think that it should be standardized … I think it should be individually, developed in the sense that, you know, there should be a framework that is, then your plan's developed within (the framework) based on your need. But I think it should be regardless of whether you've done higher duties or you're coming back from maternity leave or whatever, it's the same process. – Paramedic 8

Work engagement

In this setting, the term work engagement is representative of both positive and negative experiences of communication and its impact on perceived support for both the participants and the organisation. Information sharing, or lack thereof was frequently cited as a barrier to accessing entitlements.

We've been around the state in the last few months just asking people if they know about their entitlements and keeping touch days and less than fifty percent know about keeping touch days. – Paramedic 3

I think for people, especially women in the service, I think entitlements, especially around the maternity and stuff is all a lot of word of mouth. – Paramedic 4

Many believed this lack of information sharing was due to a combination of an inexperienced or transient management team and a general lack of communication with the parental leave cohort. The participants would often describe feeling forgotten about or dismissed by their managers. This was enhanced upon return, with most participants stating their RTCP was self-led, and they speculated if they hadn’t insisted on support, they would have slipped under the radar.

If the Officer in charge just touched base … acknowledging that you're coming back to work soon … that would be good, just some form of contact made. – Paramedic 9

I had to insist with education, I had to insist with them [line manager], I had to insist with rostering … I only got one day! Like and I even had to push for that. – Paramedic 11

As participants were discussing leadership teams, there were clear indications of deep-seated mistrust underlying their descriptions. While there were exceptions to this, it was often connected to a single person, rather than a systemic advancement. These attitudes and perceptions were evident across all geographical regions of this study. The lack of communication and engagement from line managers once again led the participants to question their value within the organisation.

At no point was I contacted … on leave, so being engaged by my employer and having the access to do CPD during that period of time would have been good. Whether I accessed it, I’m not sure, but at least then I would have known I was still part of the organization. – Paramedic 6

Ongoing engagement after the initial RTCP day or programme was raised organically by most participants, some individuals reported meaningful follow up and action taken after their concerns were raised. The other end of the scale saw follow up described as a ‘tick-and-flick’ activity, that ‘didn’t really feel genuine’ – Paramedic 12, or it was completely non-existent, even in the context of single-officer response. The frequent negative connotations surrounding ongoing engagement illustrated an ascribed meaning or value that the participants associated this with.

So, I think that could have definitely been detrimental like just being thrown in the deep end, with no frequent check-ins. – Paramedic 13

So, there was no ongoing support after that. I immediately went back on roster, in a job where I work by myself. – Paramedic 8

Clinical support

The paramedics shared a desire to be challenged in the training room, although some struggled to express this to the educators. Participants frequently sought validation from educators and clinical supervisors due to reduced confidence on return. Robust and challenging education sessions were associated with a satisfactory education experience, increased confidence and empowerment.

I feel like they also pushed me quite a lot in those scenarios. It wasn't like just like they let me float by and you know they, they pushed to ensure that I had understanding when I came back to my role and that I was still … capable and comfortable. It was like more of a supported environment, but it was still one that … when I left, I felt like I was prepared to go back. – Paramedic 2

The greatest share of participants had over 10 years of experience prior to a break in practice, which perhaps intimidated some educators. Frequent references were made to inadequately experienced educators or clinical supervisors providing unsatisfactory education, which made it clear that their perception of an adequate educator is someone more senior to them. Some felt this was another hurdle to overcome and expressed returning was already difficult ‘without their own ego challenging me’ – Paramedic 11. Others accepted this phenomenon as a sign of respect for their previous experience, despite it resulting in a perceived lack of support.

It seemed very, a bit slap happy in that it'll be fine, and I think at some point there was a bit of respect maybe afforded that because I was educating that maybe they weren't (.) like, they were trying to give me an easy pass back, but that is not supportive and actually just leaves you more vulnerable, I think. – Paramedic 6

Despite being on supported practice as part of an RTCP programme, several officers reported working as a single officer in an ambulance, identifying this as an inappropriate practice. This was somewhat accepted in rural settings; however, caused increased stress for paramedics in both metro and rural locations.

So, I was a single officer, and those shifts were quite scary … I had to think of a couple of people that I knew I could ring on the way and go through you know the case with and just discuss what cares I’d do. – Paramedic 12

Many participants requested to be rostered with another qualified officer and presumed this would be straightforward. This supervision functioned as a perceived safety net, providing comfort and reassurance during the transition back to patient-facing practice. There were several examples of when this did not occur, with participants reporting that operational demand took priority over educational needs. The participants felt that the organisations did not provide appropriate deference for the complexities of the role, placing both themselves and patients at risk of adverse events, this significantly contributed to the perceived lack of organisational support.

I had stipulated earlier on that I requested a 3-month return-to-work and that I was hoping to be rostered with a qualified officer for three months, which none of that had been actioned in any way … The realization on that first day of coming back … my first shift back on-road and realizing there's absolutely no support and that even though I’d done everything I can, I wasn't going to get what like I needed. I was so anxious. – Paramedic 9

Theme 2: The reality of flexible work

This theme was created due to the richness of the data and the importance it held for the participants. Flexible work was raised organically by the participants, and in most cases was seen as the enabler for paramedics to return to work, however, it was also associated with negative experiences attributed to misaligned expectations. The participants’ anticipation of a challenging application process was striking, as was their surprise when it went in their favour.

So even while I was still on-road, I was stressing about coming back twelve months later, not knowing whether they would be approving my rosters/shifts, with you know three kids, school, baby, family, it gets really, really stressful … So, this time around the rostering was fine and it was such a breath of fresh air. – Paramedic 1

Valuable insights were gained into the ‘reality of flexible work’. This interpretation was based on underpinning assumptions that acknowledge the intention behind flexible work is pure, however, the reality is not so. This dichotomy is reflected in these references, that imply flexibility only goes one way, and that career progression is impacted by the hours you work. This goes against the strategic objectives of most ambulance services and ultimately disrupts progress towards a fair and inclusive workplace culture.

Mostly it was just the flexible arrangement was the difficult thing more than anything, just trying to get something that worked for you when you were within very strict boundaries. So, I think if you were flexible yourself, it wouldn't be such an issue. – Paramedic 2

I returned part-time, I was originally told that my part-time agreement couldn't, well sorry, ‘informally’ was told that my part-time agreement couldn't be facilitated due to the role that I had within the system. – Paramedic 8

The disadvantages of flexible work disproportionately affected participants returning from parental leave who were required to navigate family responsibilities and long work hours. Lactation experiences seemed to be the exception to this rule, with only positive experiences discussed, however, only two participants raised the topic. There was an unacknowledged expectation that paramedics must work long hours. This cultural norm was so instilled in the group, that participants never entertained the idea that shorter days were a possibility despite reporting feelings of guilt and shame associated with long shifts.

Or actually picking a kid up from childcare as the very last kid, who is sitting on the lap of the last carer who's watching them … The poor kid's been there since the freaking crack of dawn and like that in itself just gives you the most horrendous pit of guilt in your gut. – Paramedic 11

Flexible work was underpinned by a bi-directional reality, with conflicting perceptions held by the participants, whereby flexibility comes at a price. Participants accepted this reality and associated challenges, seemingly due to a sense of gratitude for the opportunity it presents. The negative connotation of flexible work is perceived as the dominant narrative as the participants tended to justify their right to entitlement with a sense that they had ‘done their time’, ‘I did nights right up until I went on my first lot of mat leave’ – Paramedic 11. This nuanced interpretation emphasises the complexities of flexible work, further expressing the need for an innovative and sustainable approach to increased flexibility and equity in processes.

I think, we the service uses a lot of kind of flexible arrangements, part-time agreements for people that probably don't really need them within those strict boundaries…I'd never applied for anything in my life, in like the first ten or eleven years that I worked for [redacted], I never applied for a flexible roster or to have no night shifts or to do any of that, I just did what I was given. – Paramedic 2

Theme 3: Clinician identity

This theme is underpinned by the assumption that healthcare professionals possess values and qualities originating from the principles of patient-centred care. This overarching concept was highlighted in the participants’ motivation and enthusiasm to return to their role as a clinician. Their commitment to the ‘clinician identity’ was revealed through resilience and innovation when faced with adversity within the RTCP process. This involved, pre-hospital volunteer work, university-based post-graduate/re-entry to practice courses, teaching roles, alternate entry pathways, relocation and privatised emergency work, with patient safety at the forefront of everyone's mind, ‘the thing was that I felt safe in my clinical practice’ – Paramedic 3. For most, the motivating factor to return was the love of the job.

Cause I love it. I love my job, you know? I don't want to do anything else. This is it. – Paramedic 10

Participants placed high expectations on themselves in terms of their performance. This was perceived to stem from the high esteem in which they viewed paramedicine, and led to perhaps unrealistic expectations, unfair comparisons and feelings of fear, anxiety and embarrassment.

For me, it was all about getting back up to what I felt I should be as a paramedic rather than where I thought I was. – Paramedic 5

I just felt like I had so many gaps in knowledge, and I was a bit embarrassed about that. – Paramedic 12

This was understood to be a driving factor for ongoing uncertainty and reduced confidence on return. Which was often compounded by the rapid evolution of the role, exacerbating the feelings of inadequacy. Perceived expectations from colleagues also contributed to this pressure, which was seemingly inadvertent and presumed to be a continuum of the process as time went on.

In a lot of ways I still feel very uncertain and like all, am I doing it right and because there's been a lot of changes as well since I've been away. – Paramedic 7

I think people do just expect you to pick up where you left off … a lot of people are understanding, but I think as time goes on, people expect you to just, you know, go back to normal … know everything and be competent. – Paramedic 12

Return to clinical practice was viewed as an adjustment period, with several factors combined to create an overwhelming experience. Many participants also referenced ‘the little things’ in this transitional phase attributing to making them feel ‘clunky’. Such things included vehicle gear levers changing, door codes changing, to being ‘the new person’ again. These seemingly minor changes, which would typically be without difficulty, intensified the discomfort of the overall experience.

I know a lot of people get anxious about new staff and not knowing people. – Paramedic 4

I was quite comfortable. But at the same time, I was uncomfortable if that makes sense. – Paramedic 8

Participants made sense of this culture shock by finding comfort in the things that did not change, such as the patients. However, others struggled more with the concept, drawing inference to this being a reason some returners may leave the profession.

Since I've gone like you still, patients are exactly the same and you talk to them exactly the same. – Paramedic 13

And I think this is often why people retire, is that the system changes so much that you cease to be comfortable with it. – Paramedic 5

Participants described a divide of competing priorities between their identity as a clinician and the reason they were away. This is thought to be a by-product of the adaptation to the new experience and associated feelings when trying to make sense of their perceived identity shift.

Career is an important thing for me … like I do love my children, but I couldn't be a stay-at-home mum. So, there's like a very big part of me that is my job as well too. – Paramedic 2

But I think particularly as like a returning working mother your life that you've just adjusted to outside of work is so insane that when you come back to work you do not have the emotional space. – Paramedic 9

Discussion

This study set out to explore and understand paramedics’ experiences when returning to clinical practice. It was found that RTCP is inherently challenging, and participants commonly made sense of these challenges by questioning the roles and responsibilities of themselves as individual practitioners, as well as those of their organisations. The findings shed light on the lived experiences of the paramedics and determined that RTCP is multifaceted, requiring a suitable balance of flexibility within the structure. Patterns of shared meaning were created into themes and were contextualised with the theoretical framework of the organisational support theory in relation to the study's original aims.³⁸ The themes identified several factors that impact and influence a paramedic's experience of RTCP, highlighting the complexities of this transitional period, and thus the requirement for further discussion.

The first theme was labelled ‘perceived organisational support’ which encompassed three sub-themes due to the expansive nature of the topic. This was somewhat expected as specific interview questions focused on support; however, the data were subject to the participants’ experience and responses and were found to be significant. Participants raised core issues about a lack of support including inconsistent application of existing guidelines or policies, in turn, the organisation's approach to RTCP was described as unstructured, inconsistent and ambiguous. A recent study exploring paramedic experiences, albeit in a different setting, reported organisational issues as a major theme.⁴² They found that guidelines existed for the provision of support however they were not being materialised by the employer, this was similar to our results.⁴² Several studies also cite the need for structured programmes to provide supportive facilitation of RTCP for both nurses and physicians, this was strongly reflected in our paramedic cohort enhancing the transferability of these findings.^2,43–46

The importance of structure was raised with an emphasis on embedded flexibility within individualised programmes based on a personal needs assessment. Success has been reported in programmes utilising individualised curricula, with benefits noted for both clinical confidence and non-technical skills.^4,47 Ambulance organisations should strive to consider an individualised but structured approach to workforce reintegration in conjunction with existing university-based re-entry to practice courses. The structured component will ensure fairness and equity in the process, while the individualisation will allow for the array of circumstances from which paramedics return. Factors to consider include the length of time away, the reason for time away, that is, parental leave versus injury versus higher duties, etc., clinical responsibilities/skill set, single-officer response, and rural or remote locations, all of which will impact the approach to the return. This is an area requiring further research to determine what this should entail.

Work engagement and clinical supervision were found to influence perceived organisational support. Participants reported several communication barriers centred around inadequate management capabilities. A lack of communication and subsequent confusion about the process was highlighted across other studies.^6,48 Sugimoto et al.⁴⁹ reported positive experiences communicating pregnancy-related entitlements for returning doctors which reduced stress and challenges.⁴⁹ This demonstrates that accessibility of such information is crucial for the perception of enhanced support.⁴⁸ Communication issues were not limited to the initial RTCP, but were evident throughout the entire process, with recommendations for frequent managerial check-ins to provide opportunities to engage with returners.⁶ In addition, leadership deficits translated to clinical education experiences with similar struggles reported by our participants. These findings suggest that clinical supervisors require advanced interpersonal skills to nurture and support returners while providing leadership and education. This is in line with previous findings on preceptor education and its impact on the success of educational programmes.¹⁸ The organisational support theory served as an interpretive lens providing insights into the implications of these reported practices.³⁸ These insights revealed that organisations should focus on leadership development and capability and preceptorship to optimise perceived organisational support amongst the RTCP cohort.

Flexible work is a vital aspect of RTCP, it was raised organically by the participants and held personal significance. The provision of flexible work is an organisational requirement under federal law in Australia.⁵⁰ Existing research for flexible work in health professions demonstrates implications for work–life balance, career progression, childcare, financial disparity and lactation.^6,49,51–54 It was evident the issues expanded far beyond simple rostering implications, and we’ve found that paramedics are not immune to these problems. Literature on lactation experiences in paramedicine is scant, however many studies have investigated this in other health personnel, including emergency nurses who found the unpredictability of the environment impacted the ability to express/pump breast milk, associating the process with many challenges.⁶ This cohort is considered to align with paramedicine; however, our findings conveyed the opposite. This was an unexpected result, as lactation was anticipated to be a greater challenge in the pre-hospital setting, due to lack of facilities, unpredictable workload, and the urgent nature of the response. However, our findings may reflect the small sample or the lack of inquisition into breastfeeding specifically, necessitating further research into this experience. Ambulance organisations appear to have comprehensive policies and promote flexible work; however, this innovation is still overshadowed by the challenges presented, and is influenced by social norms and ambulance culture.^51,55 The challenges of flexible work are multifaceted and require equality and integrity within the process which expands far beyond written policy. Interestingly, these recommendations echo the sentiment from research in nursing RTW from over twenty years ago, which reiterates the complexities of achieving these goals, highlighting the need for further focus and investment in this area.^56,57

The strength of the participants’ connection to their clinician identity was an unexpected discovery. This was revealed through multidimensional concepts of professionalisation, self-imposed standards and competing priorities. Over the past 10 years, the professionalisation of paramedicine has seen an identity shift in individual clinicians. Previously described as thrill-seekers with a duty to respond, now are referred to as non-urgent community-based health providers, who occasionally attend a life-threatening emergency.^7,58 This shift in identity was found to impact the perspective of the returners, who felt the organisation lacked appropriate deference for the complexities of the paramedic role. This gave rise to unrealistic self-expectations, diminishing their confidence, likened to feelings they experienced as novice paramedics. Collectively, the self-imposed standards and lack of safety netting produced feelings of stress, fear and anxiety. This concept of being a new novice was also recently cited in the literature as a novel finding, suggesting an emerging theory in association with RTCP in both nursing and paramedicine.⁵ In our findings, the clinician identity was further challenged by the division of competing priorities which was dominant but not exclusive to participants returning from parental leave. Struggles of identity have been reported in medicine and nursing and are often described as guilt-driven feelings associated with the motivation to achieve in both family and work simultaneously.^5,49,59 Implementing strategies to improve reintegration with emphasis on support, empowerment and flexibility will mitigate these difficulties faced by paramedics to enhance their overall RTCP experience which is now known to be an overwhelming transitional period.

Participants shared concerns about the potential impact of neglecting the RTCP cohort of paramedics. They speculated it may affect future decisions to have children, career longevity and the propensity to leave paramedicine for a more inclusive workplace. The consequences of this are currently unknown, future research must include a quantitative analysis to determine the prevalence and scope of paramedic RTCP implications. Moreover, further investigation into the lived experience will be essential to gain a deeper understanding of the different experiences, such as those returning from parental leave versus injury and the implications these differences may present.

Limitations

This study is not without limitations. Firstly, a purposive sampling strategy was employed, and participants took part without incentive, this combination can be prone to voluntary response bias. Researchers attempted to reduce this throughout recruitment by setting clear research boundaries. Secondly, the sample included a lack of diversity, the participants were mostly females, from one geographical location, who had returned from maternity leave. This may reflect the wider population of returners; however, no research has been performed to confirm this. Social media was used to extend our reach; however, this also has constraints to known associations. This may impact the external validity of our results and may reflect the experiences of only this population. Thirdly, some participants were known to the primary researcher as colleagues or past subordinates from the same organisation. In some circumstances, this can influence the reliability of information obtained. The researchers reported interpersonal reflexivity in acknowledgement, used standardised questions and maintained participant confidentiality.

Conclusion

This study is believed to be the first insight into understanding the experiences of paramedics returning to clinical practice. Our findings demonstrate that RTCP is an extremely challenging transitional period in a paramedic's career. Contributing to the challenge was a general lack of organisational support, which manifested in several different forms, including inflexibility, inadequate communication and unsatisfactory clinical education. Contrary to this, some participants reported positive experiences when they felt supported through meaningful engagement with line managers and robust clinical education increasing confidence and competence upon return. To enhance the RTCP experience, organisations should capitalise on these strengths and strive to eliminate the barriers. The provision of structured programmes with in-built flexibility and an emphasis on building leadership capability in ambulance services should be the priority. These experiences and challenges can inform the application of organisational policy and resource allocation to better support returning paramedics in the future. These research findings should also be used as a catalyst to explore further implications of paramedic return to clinical practice as the research opportunities in the field are endless.

Supplemental Material

sj-docx-1-pam-10.1177_27536386241251429 - Supplemental material for The paramedic experience of return to clinical practice: A reflexive thematic analysis

Supplemental material, sj-docx-1-pam-10.1177_27536386241251429 for The paramedic experience of return to clinical practice: A reflexive thematic analysis by Jessica Odgers, Andrew Rochecouste and Brett Williams in Paramedicine

Supplemental Material

sj-docx-2-pam-10.1177_27536386241251429 - Supplemental material for The paramedic experience of return to clinical practice: A reflexive thematic analysis

Supplemental material, sj-docx-2-pam-10.1177_27536386241251429 for The paramedic experience of return to clinical practice: A reflexive thematic analysis by Jessica Odgers, Andrew Rochecouste and Brett Williams in Paramedicine

Footnotes

Author contributions

JO contributed to conceptualisation, methodology, formal analysis, and writing – original draft, review, and editing. AR was involved in formal analysis, data curation, review, and editing. BW was involved in conceptualisation, supervision, methodology, formal analysis, and writing – review and editing.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

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