Impact of standby points on the workday of ambulance personnel

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Impact of standby points on the workday of ambulance personnel

A study on motivation, work environment and meaningful work of ambulance personnel in Oslo

and Akershus counties

Hanne Jøtne Walsh

European Master in Health Economics and Management

UNIVERSITY OF OSLO

Master thesis – the Faculty of Medicine

Department of Health Management and Health Economics Student number: 558844

Supervisor: Halvor Nordby 30^th of June, 2019

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Title: Impact of standby points on the workday of ambulance personnel Author: Hanne Jøtne Walsh

http://www.duo.uio.no/

Print: Reprosentralen, Universitetet i Oslo

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Declaration in lieu of oath

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Abstract

Background: In 2016 the first standby point was implemented by Oslo University Hospital in Norway, in order to improve response times. There is limited previous research regarding the effects of standby points, but the research available suggest that the use of standby points have both negative physical and mental effects. This study aims to further explore the effects the arrangement of standby points have on the ambulance personnel regarding motivation, work environment and meaningful work.

Research question: How does ambulance personnel in Oslo and Akershus counties experience the impact of standby points on their workday?

Method: Two-staged approach where data from the prehospital clinic was analyzed and used to formulate possible questions for the second stage, the main data collection stage, of

qualitative one-to-one interviews. 22 respondents participated and thematic analysis was used to analyze the data.

Results: The ambulance personnel experienced that the arrangement of standby points had affected the work environment negatively regarding reduced social relations, station culture and lack of facilities. Increased focus from the management regarding response times and an experienced increase in meaningless assignments was found. Factors increasing and

decreasing motivation were identified. A majority of the respondents distinguished between the motivation for the work itself and the decline of motivation due to standby points. Standby points have negatively impacted the time and opportunity for professional development and to perform other work tasks at the station. A majority of the respondents found the work itself meaningful, but factors related to standby points have resulted in experienced

meaninglessness.

Conclusion: The results of this study shows that the workday of the ambulance personnel has been impacted by the arrangement of standby points. A combination of motivational theories and job meaningfulness can be used to describe the experienced effects of standby points. The study found that factors regarding facilities, social relations and professional development should be focused on by the management, and that implementing more standby points 2 could improve motivation and the work environment. The results also indicate a probable increase in turnover based on the negative factors found, which could lead to increased costs.

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Acknowledgements

I would like to express my gratitude for the learning experiences given to me by the study program European Master in Health Economics and Management (Eu-HEM), especially to the Management Center of Innsbruck and the University of Oslo.

To my supervisor Halvor Nordby whose guidance, laughter, enthusiasm and feedback I could not be without, I wish to convey my deepest appreciation.

A special thanks to all the participants in this study for taking the time to share information and your experiences. Your enthusiasm, dedication and passion have inspired me.

I would also like to thank the prehospital clinic at the Oslo University Hospital for their willingness to share data and letting me conduct this study, the station managers for passing on the information about this study and Per-Johnny Kohlstrunk for feedback and motivation.

Lastly, I would also like to thank Knut-Olav Hoven, my family, friends, colleagues and fellow students for the support and motivation given to me throughout my studies.

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1 Introduction

In 2000 the Norwegian Parliament decided upon indicative response times for the ambulance service in Norway. In urban settings the ambulance is to arrive at the location of the

emergency within 12 minutes in 90 percent of all cases. In rural settings the ambulance is to arrive within 25 minutes in 90 percent of all cases. This is for acute responses, often referred to as code 1 or code red (helsenorge.no, 2018). For urgent responses, also referred to as code 2 or code yellow the response time was set to be 30 minutes for the urban population and 45 minutes for the rural population in 90 percent of the cases (Norwegian Government, 2000). In 2018 and 2017 the national quality indicator showed that 65.5 and 67.5 percent of the acute responses were within the goal of 12 minutes for the urban population. Likewise, for the rural population with 78 percent in 2018 and 80,3 percent in 2017. Other countries like Denmark, Sweden, USA and United Kingdom (UK) also have indicators and goals regarding response times. Where Denmark, USA and Sweden have different goals for response times based on the geographical area or local goals, the UK has national goals where 75 percent of all patients are to be reached within 8 minutes for code red, and 95 of all patients classified with code red must be reached within 19 minutes (NAKOS, 2015; UK Departement of Health, 2011).

Of the Norwegian counties the two with the highest number of acute responses were Oslo and Akershus with respectively 23174 and 18740 acute responses during 2018. Third was Østfold county with 9026 acute responses (helsenorge.no, 2018). This thesis will focus on the two counties Oslo and Akershus. This because they are the two counties with the highest number of acute responses and that Oslo University Hospital is responsible for the ambulance service for both Oslo and Akershus counties combined.

To increase the percentage of response times within the recommended goal, Oslo University Hospital implemented standby points in 2016. Definitions and more about standby points follow in chapter 2.

At the time of this thesis very little research has been done regarding the effects of standby points. Oslo University Hospital states that there has been an improvement of the response time by 20 percent since the implementation (2019b). A master thesis study was conducted the fall of 2018 regarding the implementation of standby points in Oslo and Akershus

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counties. From the findings in the qualitative study it was mentioned that the arrangement had affected the motivation and work environment, but was not followed up extensively as it was not the main focus of the study. The study showed however that this was important and had interesting negative consequences on the motivation of the employees (Kohlstrunk, 2018).

Work environment meaning the conditions for employees at a work place, composed of physical conditions e.g. equipment and technology, factors like work processes and psychological conditions e.g. social relations (Arbeids- og sosialdepartementet, 2005;

Jakhelln & Langård, 2018).

1.1 Research question

This study aims to further the research done towards the effects of the arrangement of standby points. The main focus will be to examine the effects on motivation and work environment of the ambulance personnel. This will be conducted through a qualitative study within the ambulance department of ambulance personnel working out in the field. See chapter 4 for description of research method.

The research question of this study:

How does ambulance personnel in Oslo and Akershus counties experience the impact of standby points on their workday?

There are many perspectives in which to answer this question. I have chosen to focus on experiences and consequences of motivation, work environment, and influencing internal and external factors, based on interviews with ambulance personnel. To examine the research question and the focus factors of this study a qualitative research methodology was chosen.

This to gain knowledge of the ambulance personnel’s own experiences and perceptions of how standby points have affected their workday. Choice of methodology was also based on gaining knowledge that quantitative data received from the clinic could not explain, and to examine whether motivation, the work environment or other factors are affected by the arrangement of standby points. The results from the interviews were analyzed using thematic analysis, which is a widely used qualitative analytic method. This method uses a six phase guide of analysis, to sort and code the data, and gives freedom to explore both theory-driven themes and data-driven themes, i.e. that the themes extracted from the data can be based on

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3 the research question or from the data itself (Braun & Clarke, 2006). This method of analysis seemed to best suit this study because of the flexibility to analyze the data with both the research question in mind and to discover new themes based on the raw data relevant to the study.

Theories of motivation including the basic need hierarchy, motivation-hygiene theory, self- determination theory and job meaningfulness will be used as the theoretical framework to compare the results. Chapter 3 will focus on describing motivational theories and job

meaningfulness and subchapter 6.2 will analyze to which extent existing motivational theories are applicable to discuss the findings.

1.2 Choice of topic

The reason for choosing to research ambulance personnel in Oslo and Akershus counties is based on my experience from my internship at the Prehospital Clinic at Oslo University Hospital, who is responsible for the ambulance service. I observed a high focus and

satisfaction of the reduced response times in their responsible area (Oslo University Hospital, 2019b). During this time, I also had the opportunity to intern at the Emergency Medical Communication Centre (EMCC) and in an ambulance during an evening shift. This to experience the different departments of the clinic. I’ve also worked at the Norwegian Directorate of Health in the department for emergency medical services and preparedness which has been an inspirational factor to see the healthcare system from a governmental viewpoint and my introduction to the response time quality indicator (helsedirektoratet.no, 2019).

During my internship I experienced being on a standby point and reactions from the ambulance personnel. I also got information about the implementation and development of standby points, which at the time was the only one of its kind in Norway. During this internship I experienced the ambulance personnel I met as highly enthusiastic, professional and eager to pass on their knowledge to others. However, many had very strong opinions regarding standby points and their effects on work environment, job engagement and on patient care. It has therefore been natural to assume that the arrangement and this different way of working, which has increased time spent in the ambulance and decreased time at the station, could have an impact of on their workday both physically and psychologically.

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Reasoning for choosing this topic of interest was based on the findings from the study done by Kohlstrunk, the signals experienced from the field and the interest to further study whether standby points can have a negative effect on the work environment and motivation

(Kohlstrunk, 2018). These factors together with advice from my supervisor lead me towards the topic at hand, to research how the arrangement of standby points impacted the workday of the ambulance personnel, specifically their work environment and motivation.

Overall goals of the study is that the findings can benefit the ambulance personnel and the clinic at Oslo University Hospital to further improve their service, to inspire others to do research in this field to increase comparability and learning between different ambulance services and that the findings might be used in the decision-making process of other prehospital clinics in Norway or other countries when contemplating introducing standby points in order to reduce response times.

1.3 Importance of study

There has not been done much research on the topic of standby points, especially in regards to the effects the arrangement has on the ambulance personnel (see subchapter 2.5). This study will therefore contribute to shed light on this matter and hopefully inspire others to further research this subject.

The topics of this thesis, regarding standby points as an arrangement to improve response times and effects that this arrangement can have on the workday of the ambulance personnel, are applicable to other areas of Norway and other countries. The findings in this thesis can be used by ambulance services that either have standby points, have dissatisfying response times and/or are in need of new procedures to reach the recommended response times set by the government. In subchapter 2.5 further research and findings from other countries will be highlighted, which in subchapter 6.1 will be discussed to find similarities and differences between the arrangement in Oslo and Akershus counties and other countries.

By trying to find elements that affect the work environment of ambulance personnel and what motivates them, this study might create more understanding towards their expectations of the work place, processes and work tasks. This thesis has therefore emphasized on the findings regarding work environment, motivation and quality, and discussed as to how the results of

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5 this study can contribute to improve the workday and results for the ambulance personnel and the clinic as a whole, with emphasis on the arrangement of standby points.

By giving insight into the experiences of the ambulance workers in the field, the management of the clinic and others who are thinking about implementing standby points to reduce

response times, can identify factors that lead to increased meaningfulness of work, improved work environment and increased motivation.

The thesis will consist of the following chapters; background with definitions and

explanations of the implementation of standby points, data from the prehospital clinic and previous research, theoretical framework, research method with explanations of how the research was conducted, results and conclusion.

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2 Background

Oslo University Hospital has the responsibility of the ambulance service for Oslo and

Akershus counties, serving approximately 1287495 people (Akershus fylkeskommune, 2018).

This thesis focuses on actions done to improve the response times in this area. The

implementation of standby points is a measure that falls within this category and will be the arrangement focused on in this study.

2.1 Standby points

In 2016 the first standby point for ambulances was implemented and established in the ambulance region of Oslo and Akershus in Norway. The ambulance service is organized into five ambulance regions. The northern region includes three ambulance stations: Nes,

Nannestad/Ullensaker and Eidsvoll. The eastern region includes four ambulance stations:

Aurskog/Høland, Lørenskog, Nittedal and Brobekk. The central region includes the two ambulance stations Ullevål and Sentrum. The southern region includes three ambulance stations: Nordre Follo, Søndre Follo and Prinsdal. The western region includes the three ambulance stations Smestad, Asker and Bærum (Oslo University Hospital, 2019b). The ambulance department is one of the largest in Norway with approximately 450 employees, excluding students and interns, and has approximately 170 000 ambulance assignments yearly (Ambulanseforum, 2019; Oslo University Hospital, 2019b).

In Oslo and Akershus counties a standby point is a predetermined ideal geographical point.

More specifically defined as a place or location with the goal to improve the accessibility of an increased number of patients in the least amount of time, with an ambulance resource (Kohlstrunk, 2018). This includes criteria like quick/close access to roads and the possibility to reach emergency situations within 12 minutes of the location with more or less no reaction time. The standby points are located at gas stations close to main roads in the counties, and are used between 07.30-22.00 o’clock (Ambulanseforum, 2019; Prehospital klinikk, 2019).

An ambulance is not to stay at a standby point for longer than 60 minutes before rotation occurs (Prehospital klinikk, 2019).

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7 I have not been successful in finding any documentation on procedures stating how many times during a shift an ambulance can be sent to standby points. This seemingly lack of standard procedures and/or communication and use is reoccurring in this study, see chapter 5 for further description. Based on the internal procedure document of the prehospital clinic, what here is mentioned as standby points is called active standby points, and standby points 2 are called fixed standby points (Prehospital klinikk, 2019). Because the interviewees have only used the terms standby points and standby points 2, this will be used in this thesis.

It was originally introduced five standby points in Oslo and Akershus counties: Abildsø, Grorud, Strand, Vinterbro and Skedsmokorset (Oslo University Hospital, 2019b). The first standby points were implemented in June 2016 at the location of Grorud, followed by Abildsø and Skedsmokorset in December the same year. The remaining two standby points were implemented in May of 2017.

Figure 1. Standby points geographically

In figure 1, red dots are the original standby points and green triangles are ambulance stations in the geographical area of Oslo and Akershus counties, based on the information from Oslo University Hospitals webpage (2019b).

Grorud

Skedsmokorset Strand

Vinterbro Abildsø

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A standby point 2 was implemented the 1^st of September 2018 at the location Ryen. This as a replacement for the standby point at Abildsø (Oslo University Hospital, 2019c). Standby points 2 differs from the regular standby points due to the facilities provided there. At a regular standby point there are no facilities provided by the employer except for the vehicle itself. If applicable the ambulance personnel can use the facilities at the gas station at its location, but are to remain in the vehicle or very close proximity to the ambulance at all times (Ambulanseforum, 2017). A standby point 2 is a building located at a different geographical location than the station, where the ambulance personnel can be in emergency preparedness.

The location of the standby point 2 is geographically mapped to allow quick access to main roads and also reduce the time the ambulance personnel need from they receive an assignment to they are on their way to the location of the emergency (Oslo University Hospital, 2019b).

At location Ryen there are facilities for the ambulance personnel like bathrooms, a kitchen and a seating area, a TV, wireless internet and an area for rest (Oslo University Hospital, 2019c). At the regular standby points the ambulance vehicles must always be on idle speed to keep the vehicle warm and the medical equipment functioning (Ambulanseforum, 2019). At the standby point 2 this is done by an electric cable connected to the vehicle. Standby points 2 will be operational 24 hours a day, and at location Ryen serve a population of 140 000 (Oslo University Hospital, 2019c). At a standby point 2 rotation occurs if there is no assignment given within 4 hours (Prehospital klinikk, 2019). As we will see further on, this difference between standby points and standby points 2 is experienced as crucial for the informants and will be relevant in the discussion.

2.2 Background for the implementation of standby points

The background for this implementation, of change in work routine, was that some areas of responsibility did not reach the national goals and internal goals for response times. Response time is defined as the time from when the phone rings at the EMCC to the ambulance has arrived at the location of the patient. The goal for urban areas in Norway is 12 minutes for 90 percent of the population for acute responses (Norwegian Government, 2000). The definition of a urban area is based on the population of a county, and has to have a population of more than 10000 inhabitants (helsenorge.no, 2018). Per 1^st of January 2018 Norway has 422 municipalities, where 41 are under the responsibility of the prehospital clinic of Oslo University Hospital (helsenorge.no, 2018; Oslo University Hospital, 2019a). For rural areas

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9 the goal for response times is 25 minutes for 90 percent of the population for acute responses, and contains less than 10 000 inhabitants (helsenorge.no, 2018; Norwegian Government, 2000). The standby points are meant to increase and optimize the emergency preparedness in a normal situation with active/dynamic control of the ambulance fleet. Active/dynamic control refers to pre-positioning of an ambulance resource so that it is closer to expected calls for service. This differs from emergency preparedness transfer or emergency preparedness allocation where one relocates ambulances when the area is lacking ambulances, or to

increase the emergency preparedness. Emergency preparedness transfer is often used when an area is lacking ambulances because they are on an assignment. Another ambulance is then allocated to the geographic area until the ambulance stationed in the area returns.

2.3 Project focus

The focus of this study is how the arrangement of standby points have affected the workday of ambulance personnel by studying factors of motivation, work environment and job

meaningfulness. The arrangement has led to increased time sitting in the ambulance and with their partner, less time at the station, and few or any facilities at the standby points. It has been extensively shown that negative interpersonal interactions i.e. social relations at the work place, lead to higher levels of job dissatisfaction, turnover intent and negative mental health outcomes for employees (Reich & Hershcovis, 2011). Research findings also indicate that a negative and/or poor work environment could lead to reduced motivation, satisfaction and performance, as well as increased turnover (Bradley, Burns, & Weiner, 2012).

Consequences of the arrangement and the personal implications for the ambulance personnel has not been studied, and represent an important reason for this study. Research has shown the importance of managerial practices focusing on improved motivation, and that highly motivated and high quality personnel is an advantage difficult to replicate and can lead to improved performance (Bradley et al., 2012; Huselid, 1995; Zigarelli, 1996). This also means that limited focus on motivation and unmotivated personnel could affect the performance negatively, e.g. if the arrangement of standby points affect motivation negatively, this could affect the results of the service and potentially the care of the patients (see chapter 5 and 6).

In order to understand the impact of standby points on the workday of ambulance personnel, this the project was divided into two stages. Firstly, retrieving data from the prehospital clinic

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at Oslo University Hospital and analyze them to see if there were tendencies showing a change after the implementation. This however was not the basis data of this study, but used to formulate possible questions for the second stage, the main data collection stage, of qualitative interviews.

2.4 Status of indicators in the prehospital clinic, Oslo University Hospital

Figure 2. Self-resignation

Figure 2 shows total turnover from 2016 to 2018, divided into self-resignation (25-Egen oppsigelse), resignation (45-Avskjed/Oppsigelse), other causes (50–Annen sluttårsak) and unknown (Ukjent) for the prehospital clinic.

Compared to the other stations there is a higher turnover for the ambulance stations located in the central and populous areas of Oslo and Akershus counties, where more than half of the total turnover occurred. Causes looked at were the categories of unknown, self-resignation and other causes. The highest number of turnovers was found in the period of the

implementation of standby points in 2016. Of these more than half was from the central areas of Oslo. In a central station 10 turnovers was registered as unknown during December 2016.

This might have others causes than that the reason for the turnover is unknown. It could be a registration error in the data or caused by reorganization e.g. transfers to other stations, and will not be focused on in this thesis.

The total self-resignation has doubled every year from 2016 to 2018, from 5 in 2016 to 20 in 2018.

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Figure 3. Use of overtime

The figure shows use of overtime (Overtid), variable wages (Variabel lønn) and hourly wages (Mertid/timelønn) in full time equivalents from 2014 to 2018 for the 5 ambulance regions in Oslo and Akershus counties: central region (AMBTM), north region (AMBTQ), south region (AMBTR), west region (AMBTV) and east region (AMBTØ). Full time equivalents is a unit of measure and consist of either an employee working with a full-time contract or two or more employees with a part-time contract (Heery & Noon, 2017). Value of “Totals” are the median month over the time period. Each cell represents the median month of that year and type. The prehospital clinic understands the use of overtime, variable wages and hourly wages as working hours outside the normal contract, and could be related to the coverage or decrease in general coverage based on high use of the factors. Even though there is use of overtime, hourly wages and variable wages in the ambulance regions this does not mean that there are more people working, but rather using the resources available through prolonged workdays and extra shifts.

There is a stable or somewhat increase of variable wages in the time period after the implementation and decreasing and/or stable usage of overtime.

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Figure 4. Short time sick leave or leave

Figure 4 shows the median month percentage short time sick leave or leave in the 5 ambulance districts in Oslo and Akershus counties from 2014-2018: central region

(AMBTM), north region (AMBTQ), south region (AMBTR), west region (AMBTV) and east region (AMBTØ).

The usage of sick leave or short time leave has been stable over the last 5 years with a seemingly higher total usage in the central district.

2.5 Previous research

Research regarding dynamic ambulance deployment has been done in several countries. The introduction, research and implementation of dynamic ambulance deployment has been related to the emergency medical service using response times as a quality indicator of the service provided, the publics’ interest and expectations, and as an option of deployment based on limited resources. As the provider of ambulance services cannot continuously expand their fleet of ambulances and personnel due to limited budgets and resources, different options have been identified and dynamic deployment has been indicated as an attractive option (Lam et al., 2015).

Dynamic deployment is to pre-position ambulance resources so that they are closer to expected calls for service (Loberger, 2016). Much of the research found regarding dynamic deployment are of the programming tools and calculations to improve the response times and deployment of ambulances. Research on empirical data from Vienna showed that by using approximate dynamic programming the response times would be reduced by 12,89 percent, but that regulation of moving an idle ambulance to another location had to be changed to be

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13 able to accomplish the results (Schmid, 2012). Research from Singapore regarding

approximate optimal dynamic deployment plans showed similar results, that response times could decrease if the suggested policy was implemented (Lam et al., 2017). Similar results was found in Turkey with an average reduction of response times of 5 minutes using a demand and geospatial-time based dynamic ambulance deployment strategy (Swalehe &

Aktas, 2016). Research also concluded that dynamic ambulance deployment resulted in significant lower response times and coverage of service in the area of study compared to static ambulance deployment policies (Lam et al., 2015). Static deployment meaning that ambulances are on fixed stations when on standby between calls, i.e. drives back to their respective station after an assignment to be on standby (Wu & Hwang, 2009). Similar findings from Canada and Israel, was found, where response times decreased when

implementing a dynamic deployment through simulation (Maxwell, Henderson, & Topaloglu, 2010; Peleg & Pliskin, 2004).

In the United Kingdom, dynamic deployment i.e. the practice of moving ambulance resources closer to where the predicted source of the next call will be, has been implemented. The rationale for implementing the standby positions are quicker resource mobilization and that their location may reduce response times (UK Departement of Health, 2007). There is little available research and/or data of the actual use and arrangement of standby points, except for a policy document from the South Central Ambulance Service NHS Foundation Trust (SCAS) who serves a population of approximately 7 million people (South Central Ambulance

Service NHS Foundation Trust, 2019). In SCAS standby points are defined as strategically placed locations that enable a rapid response to patients. They are designated a star rating between zero and three, dependent on the amenities available. Star rating zero are roadside locations with no facilities and have a maximum stay of 60 minutes. Star rating one has basic facilities like toilets and the possibility to make refreshments, and are often located at fire stations or other co-located buildings, and has no limit of stay. Star rating two are similar to star rating one, but with adequate facilities that could include restrooms, IT equipment, telephone and are often located in porta-cabins or adapted industrial units, which some can be used for meal breaks. Star rating three are similar to star rating two, but are suitable for meal breaks, use of facilities, vehicle check and restocking, and is defined as a Resource Center (South Central Ambulance Service NHS, 2018).

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With regards to research of response times and patient care, studies show that there is little evidence relating response times targets of 8 minutes and improvement of patient care. Price suggests that existing literature is conflicting and that further research and reviews are needed (Price, 2006). From the study done by Price in the UK, paramedics believed that the target response times were achieved at the expense of quality of care and patient outcomes. Other findings were that a majority of the paramedics in the study believed that the standby points were not achieving its purpose and not benefitting the patient, and skepticism regarding the reliability of the statistics and manipulation of the response times by the thrust. In relation to sickness absence rates, they were found to be the highest amongst ambulance trusts and the paramedics linked this towards the response time targets and the impact it has on health, safety and wellbeing. Standby points were particularly mentioned in regards to the lack of facilities, company, crew room support, external factors and that the ambulances are not ergonomically designed to sit in for long periods of time. This resulted in reports of increased prevalence of back pain and discomfort which affected their performance of patient care. It was also stipulated that there could be long term consequences for the mental health of the paramedics, due to reduced or removal of the ambulance station culture and its benefits on dealing with work related stressors. Findings also showed negative effects on the morale, enthusiasm and the willingness to take on other responsibilities (Price, 2006; Price et al., 2005). A similar study from the United Kingdom found that many paramedics felt that in general their professional and advanced skills were inappropriately used, where the majority of jobs were believed to be trivial, time wasting and inappropriate (Price et al., 2005).

Given this limited research, even around dynamic deployment, there is still much we do not know regarding the organization of the ambulance service in order to reduce response times.

This study aims to hopefully not only enrich research regarding Norwegian conditions, but also have international impact. Regardless of response time goals and strategies for reducing the response times e.g. dynamic deployment and standby points, the findings in this thesis will be relevant in a national and international setting. This in regards to potential

implications on the work environment and motivation based on the general idea that the emergency services are spending time in the ambulances away from the station in order to be closer to potential emergencies.

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3 Theoretical framework

Motivation is defined as a state of feeling and/or thinking in which one is energized or aroused to perform a task or to engage in a particular behavior (Bradley et al., 2012).

Motivational theories are used to understand what motivates and how this can be used by managers to increase motivation at the workplace. This chapter will present theories that shed light on motivation factors and job meaningfulness, and can be used to further understand the findings from this study.

3.1 Intrinsic and extrinsic motivation

Motivation is generally divided into two categories based on different reasons or goals that give rise to an action; intrinsic and extrinsic motivation. Intrinsic motivation is defined as performing or doing an activity based on the inherent satisfactions rather than for some separable consequence i.e. doing something based on an inner wish or drive rather than doing it for an external reward or pressure (Ryan & Deci, 2000). This could include the satisfaction of achieving a task, a sense of achievement and finding something interesting, challenging or fun (Jeanes, 2019b). Extrinsic motivation is defined as performing or doing an activity in order to attain some separable outcome, i.e. based on the desire for an external reward (Ryan et al., 2000). This could include physical or psychological rewards like pay, bonus,

recognition or praise (Jeanes, 2019a).

3.2 Basic need hierarchy

Maslow’s basic need hierarchy is one of the most known and influential models of

motivation, as well as one of the earliest (Bradley et al., 2012). The theory argues that five basic levels of needs must be satisfied. Maslow argues that the basic human needs are

organized in a hierarchical manner due to that once a need is satisfied, a new and higher need will emerge and dominate the person, and so on.

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Figure 5. Basic need hierarchy

The first basic need is the physiological needs which include food, air, water and shelter (Maslow, 1987). From a managerial point of view this would entail adequate wages and physical work environment i.e. temperature, facilities, lighting and ventilation (Bradley et al., 2012). The second level is safety needs which includes physical and phycological factors including security, stability, dependency, protection, freedom for fear and anxiety and need for structure, law and limit (Maslow, 1987). Examples from a managerial perspective would be the need to be free from worry about security or money, i.e. retirement packages, a

grievance system, job security and so on (Bradley et al., 2012). Belongingness and love needs will emerge if the previous needs are fairly well met, involving giving and receiving affection (Maslow, 1987). In a work setting this would include acceptance from peers, friendships at work, social interaction and being part of a team (Bradley et al., 2012). Level four, the esteem need, is classified into two sets of needs; self-esteem and self-confidence, and the respect or esteem from other people, i.e. the personal need for esteem and a need for recognition or esteem from others (Maslow, 1987). In a work setting this could be a feeling of

accomplishment and receiving recognition, where the latter is an extrinsic motivation factor (Bradley et al., 2012). At the top of the hierarchy is self-actualization needs, to become everything that one is capable of becoming (Maslow, 1987). In a work setting this would entail professional development and involvement in decision making (Bradley et al., 2012).

Self- actualization

needs Esteem needs Belongingness needs

Security needs Physiological needs

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3.3 Motivation-hygiene theory

Herzberg’s motivation-hygiene theory, often referred to as the two-factor theory, argues that there are two factors associated with job satisfaction and high motivation and with

dissatisfaction and low motivation, called motivators and hygiene (Bradley et al., 2012). The factors related to job satisfaction and high motivation including professional and personal growth, recognition, the work itself and achievements, are labeled motivators. These factors are intrinsic factors and if present will lead to job satisfaction and motivation. On the other hand, if not present will not lead to job dissatisfaction (Herzberg, Mausner, & Snyderman, 1993). The factors related to job dissatisfaction and low motivation including supervision, interpersonal relations, physical working conditions, salary, company policies, administrative practices, benefits and job security, are labeled hygiene factors (Bradley et al., 2012; Herzberg et al., 1993). The hygiene factors are related to the work environment and if found negative job dissatisfaction results (Bradley et al., 2012). On the other hand, if positive they will prevent dissatisfaction, but will not result in job satisfaction or motivation (Bradley et al., 2012; Herzberg et al., 1993).

A representation of Herzberg’s two factors can be shown based on the figure below.

Figure 6. Hygiene and motivator factors

Hygiene factors

• Supervision

• Interpersonal relations

• Physical working conditions

• Salary

• Company policies

• Administrative practices

• Benefits

• Job security

Motivator factors

• Professional growth

• Recognition

• Achievements

• The work itself

• Personal growth

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3.4 Self-determination theory

Self-determination theory (SDT) has been used in research regarding motivation for

education, work and healthcare, and focuses on three basic phycological needs that must be satisfied for sustained wellness, development and interest, and to achieve motivation needed to perform an activity (Deci, Ryan, Hunsley, et al., 2008; Ryan & Deci, 2017). The needs are autonomy, competence and relatedness. Autonomy refers to experiences and actions being decided by oneself wholeheartedly, i.e. self-regulation and self-organization (Deci & Ryan, 2000; Ryan et al., 2017). When an individual has achieved this need SDT argues that they better regulate their own actions in agreement of their felt needs and available capacities. This would lead to improved coordination and prioritization processes and would result in

enhanced well-being and task performance (Deci et al., 2000). Competence refers to the need to feel mastery, being able to operate effectively, and interactions in social relations.

Constructive feedback, good communication and social relations in the work place increase the feeling of mastery and professional confidence (Ryan et al., 2017). The need for

competence leads people to professional growth, specialization and to pursue challenges fitted for their skill set. It is an intrinsic motivation that leads to cognitive, motor and social growth (Deci et al., 2000). Relatedness refers to feeling socially connected, by the feeling of

belonging and being cared for by others and contributing, giving and caring for others (Ryan et al., 2017). The need for relatedness increases resource sharing, support, social relations and knowledge transferal within the workplace (Deci et al., 2000).

As well as the basic phycological needs, SDT also differentiates between different types of motivation, especially autonomous and controlled motivation. Autonomous motivation consists of intrinsic motivation as well as the types of extrinsic motivation where one has identified an activity’s value, and involves behaving with a full sense of volition and choice.

Controlled motivation involves behaving based on experiences of pressure, punishment, demand, and factors like approval motive and avoidance of shame, towards an outcome perceived to come from forces external to oneself. When controlled, people are pressured to think, feel or behave in a particular way (Deci, Ryan, & Hunsley, 2008; Deci, Ryan, Hunsley, et al., 2008).

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3.5 Job meaningfulness

Through their research Bailey and Madden found five qualities of meaningful work and seven factors increasing meaningless work (2016). They argued that meaningful work was highly motivational and could improve job satisfaction, commitment and performance (Bailey &

Madden, 2016). Meaningfulness was associated with the feeling of achievement, professional development, achieving one’s potential, praise, recognition and acknowledgment. The five factors of meaningful work identified were:

• self-transcendent

• poignant

• episodic

• reflective

• personal

Self-transcendence refers to work being meaningful when it matters to others more than oneself, i.e. the impact or relevance of the work done on other individuals or groups. Poignant refers to work being meaningful when faced with mixed feelings during moments of work both in regards to happiness and joy, but also un-comfortability and painful moments.

Episodic refers to the feeling of meaningfulness not being sustained or constant but arose episodically, but had a prolonged affect emotionally and personally. Reflective refers to that job meaningfulness usually is achieved in retrospect and during reflection of episodes in a work setting, and the consequences of one’s actions for others than oneself. Personal refers to job meaningfulness being achieved when understood in the context of their personal life experiences, i.e. appreciation or recognition from others internally and externally in the work setting (Bailey et al., 2016).

In general, the feeling of meaningfulness comes from the employee themselves. On the other hand, meaninglessness was found to be linked to how the employees were treated. The seven factors creating meaninglessness were:

• disconnecting people from their values

• take your employees for granted

• give people pointless work to do

• treat people unfairly

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• override people’s better judgment

• disconnect people from supportive relationships

• put people at risk of physical or emotional harm

The first factor relates to the disconnect between the values of the employee and that of the management, i.e. the managements’ focus versus the individuals focus of quality or

professionalism. The second factor relates to the employee’s feeling of being unrecognized, unappreciated or unacknowledged by managers either in direct line or the management itself.

The third factor is related to performing tasks that does not fit the views of the employee of what the work should entail and how the time at work should be used. The fourth factor relates to distributive injustice and procedural injustice. I.e. one’s perceived unfairness of outcomes such as payments and to the unfairness of the procedures used to determine one’s outcome and decisions such as lack of career progression or bullying (Afzali et al., 2017;

Bailey et al., 2016). The fifth factor relates to the feeling of disempowerment regarding how work is done, i.e. the feeling that opinions and experienced are not appreciated and not being listened to. The sixth is linked to being deliberately excluded by managers or being isolated or disconnected from coworkers. The opposite was argued to increase meaningfulness in regards to social relations and friendship between coworkers. The last factor differentiated between the physical and emotional harm that many jobs entail and the unnecessary extra exposure to risk, e.g. health care worker being left alone with an aggressive patient (Bailey et al., 2016).

Increased job meaningfulness is argued to lead to a more attractive organization with motivated employees and decreased turnover.

The theories in this chapter could have been described in further detail, but that would fall outside the guidelines of this thesis. The goal is that the reader shall understand the central concepts and definitions to understand the arguments presented in the discussion. As we will see, the theories presented will be relevant to discuss the findings in this study.

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4 Research method

4.1 Qualitative research method

There has been very little research on the field of standby points in Norway. The only exception being the master thesis regarding the implementation of standby points

(Kohlstrunk, 2018). There has been research on the topic from other countries, as presented in chapter 2.

To gather understanding of the workday of the ambulance personnel in Oslo and Akershus counties the choice of method best suited to describe the situation and against the background information provide an explanation, was qualitative research design (Justesen & Mik-Meyer, 2012). A quantitative research methodology would not be suited to explore, gather deeper understanding and further describe and explain the experiences, opinions, thoughts and knowledge of the ambulance personnel. As a goal for this study was to gather new in-depth information of their understanding regarding their workday, an exchange of words between two people, between the interviewer and interviewee was needed. This would have been difficult to find through analyzing quantitative data like questionnaires (Malterud, 2017). This because in order to explore their experiences the flexibility of a dialogue is needed, because people often express themselves better orally than in writing. A questionnaire could also decrease the willingness to participate because it would require more time of the respondents due to the amount of questions asked, as well as forming questions that would give answers providing knowledge of their experiences, opinions and thoughts regarding their workday, could be very difficult to do (Chasteauneuf, 2010).

Primary data was collected through interviews. The interviews were semi-structured where the questions were pre-determined. Choice of semi-structured interviews was to enable the interviewer and the interviewees to deviate from the interview guide to bring up unexpected and interesting topics, as well as to generate new knowledge and stimulate the interviewees to reflect over the same pre-selected questions (Justesen et al., 2012). One of the questions was more typical of a structured interview where the interviewees were to list up the 3 most important motivational factors of their work (attachment I). The interview guide had a limited

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number of questions as to give the interviewees the opportunity to present their opinions and stories.

4.2 Data collection and study sample

Data from the Prehospital clinic was received after meeting with the leader of the Ambulance department and the manager of economics for the prehospital clinic. The meeting was to inform about the planned research and possibilities of data extraction. Datasets regarding response times, sick leave, turnover, use of overtime, how many percent during a day an ambulance is not at the station and employee surveys from 2014 until 2018, was requested.

Datasets on sick leave from 2014-2018 on station level, turnover from 2016-2018 as the clinic did not have data from 2014-2015, and FTEs (full-time equivalent) which included overtime and variable pay from 2014-2018, was received.

22 interviews with ambulance personnel from the ambulance department was conducted. Both sexes were represented, with a majority of male interviewees. The sample represented stations in central and rural areas.

The selection criteria for the study was that the interviewees had knowledge about standby points and to be ambulance personnel in Oslo and Akershus counties. The selection criteria were wide as to receive as many interviewees as possible. An information and consent letter was sent to all the stations to be placed in the common areas as well as given to station managers during one of their meetings (see subchapter 4.6 and attachment II in Norwegian).

Further description of the research method and the process has been divided in the next three subchapters; planning phase, execution phase and analysis.

4.3 Planning phase

The interview guide consisted of 4 questions based on the background data from the

prehospital clinic, the research question and discussions with the supervisor. The goal was to select topics and the sequence of the questions to achieve both thematic and dynamic

dimensions. This to receive answers to the research question and leave room for spontaneous or unexpected answers (Kvale, 1996). Based on preconceived knowledge of the busy

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23 schedules of the ambulance personnel and to receive a higher number of interviews to

strengthen the findings in the thesis, the student and supervisor agreed to limit the number of questions to four and to set a time frame of approximate 20 minutes for each interview. This was also done due to the time constraint of the thesis and the do-ability to transcribe and analyze the findings within the set deadlines. The choice of semi-structured interviews was also to ease the structuring of the interviews for analysis (Kvale, 1996).

A test interview was performed on an interviewee without knowledge of the topic to ensure that the questions asked were easy to interpret. Minor changes were done to improve the questions based on this test run. The questions were also discussed with the supervisor to ensure that the potential feedback of information gathered from the interviews was sufficient to produce findings. The order of the questions was also improved so that the opening

question asked would yield a spontaneous and preferably rich description of the experience of the interviewee within the theme (Kvale, 1996).

4.4 Execution phase

The data for the thesis was collected in two stages. The first stage was the quantitative data described in chapter 2 from the prehospital clinic, which was analyzed using simple formulas of summation, average and percentages. This data was not the primary data for this thesis and was used for the background and for the interview guide. This due to time constraints and that the data set provided was more limited than first anticipated (see subchapter 4.2). The primary data for the thesis and analysis was collected through interviews.

4.4.1 Interview

Before the interviews the interviewer always controlled whether the information letter and consent were received. If not, the interviews would start by ascertaining whether the interviewee consented to the participation either by written consent or recorded orally.

The interviews would follow the interview guide, with some alterations like follow-up questions done ad hoc to ensure answers to all the questions. Follow-up questions were planned to be spontaneous from the interviewer during the interview, but one follow-up question was pre-set if not mentioned by the interviewee. Specifying questions were asked if

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the interviewer wanted to get more precise descriptions. Even with the test interview the interviewer experienced a steep learning curve while conducting the interviews. This especially in not rushing the questions and the use of silence to give the interviewee time to reflect and associate with the theme in question, and break the silence themselves with significant information (Kvale, 1996). This was also used to ascertain from the interviewer’s side that the query was fully answered and the next question could be asked.

The interviewer would explain how many questions the interview would contain, and inform when the last questions was asked. After asking all the questions, the interviewer would enquire whether the interviewee had any questions or anything further to add. The interviews followed the recommend phases of Gillam, ending with the appreciation of the interviewer of the time spent by the interviewee and information regarding the process of the research (Gillham, 2005; Justesen et al., 2012).

The majority of interviews were done over telephone. This due to the time constraint of the thesis both in regards to planning and also travel time. Face-to-face interviews were done at different locations, based on the interviewer or interviewees preference, or availability; at the ambulance station, at the University of Oslo or other locations e.g. cafés.

4.4.2 Saturation

Data saturation, in this thesis meaning how much data is needed before nothing new is apparent and data collection can stop, was reached at 20 interviews (Saunders et al., 2018).

The student opted to continue interviewing until 22, to strengthen the decision that saturation was met. Saturation in the setting of interviews is when the interviewer hears the same points and similar answers over and over again. At this point data saturation is reached and the researcher can start analyzing the data (Saunders et al., 2018).

4.5 Analysis

Thematic analysis, as described by Braun and Clark, has been used when analyzing the data gathered from the interviews. A theme is defined as something important in the dataset, that gives meaning, and that relates to the research question (Braun et al., 2006). The approach chosen for this thesis is a realist approach with the assumption that through interviews and

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25 therefore language, will let the interviewee reflect and articulate their experiences and

meaning. In analyzing the data, the six-phase guide described by Braun and Clark has been used. A short summary of the six phases follows before a description of the transcription and analysis.

First phase is to familiarize oneself with the data through multiple readings as to start forming ideas of coding, as well as transcription. This phase is time consuming, but provides the bedrock for the entire analysis, and must therefore not be skipped. For the transcription the requirement for this thesis was a verbatim account of all verbal utterances, with focus on keeping the transcription accurate to its nature and contain the information needed for the analysis (Braun et al., 2006).

The second phase is to generate initial codes. Codes are defined as features of interest to the analyst from the raw material from the transcription. Coding can be done either manually or by using a software program. Manually this can be done by writing notes or color-coding potential patterns. All data must be coded and collated into groups consisting of a code (Braun et al., 2006).

The third phase consists of searching for themes, the units of analysis. These can either be

“theory-driven” or “data-driven”, i.e. depend on specific questions the researches wish to analyze or be dependent on the data at hand. The codes found in phase two will in this phase be grouped to form overarching themes (Braun et al., 2006).

The fourth phase is refinement and review of the themes found. If too diverse data or not sufficient data to support the themes, they must be discarded. Other themes might be joined or separated to achieve themes with data that cohere meaningfully and that are distinct from each other. Revision of the raw data and additional coding is recommended in this phase, also additional revision and forming of new themes. By the end of this phase a thematic map of the data, including the different themes, the connection between them and the overall story of the data, should be achieved (Braun et al., 2006).

The fifth phase consists of refining and defining the themes, determining which data each theme includes, which sub-themes are included and what each theme contributes to the overall analysis, i.e. refine and define each theme themselves and in relation to the other themes (Braun et al., 2006).

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The sixth and final phase is writing the report that validates and merits the analysis and tells the story of the data collected (Braun et al., 2006).

4.5.1 Transcription

Transcription in this thesis, was to transcribe the audio recording of the interviews to text. As the interviews were done in Norwegian, they were also transcribed in Norwegian. The

interviews were transcribed verbatim, as to keep the transcribed text as close to the verbal utterance. Nonverbal utterances were not transcribed, as this would have been too time consuming.

The interviews varied in length, but were generally 20 minutes long. The interviewer always asked if the interviewee had questions regarding the project or if they had anything else to add. Some of the interviews had a duration of approximately 60 minutes, which also included information about the study and other conversation. When transcribing the focus was on the answers of the interviewee regarding the questions asked, and if they had other information to add that they forgot to mention in the initial phase. The interviewer also informed of the possibility to send or contact the interviewer again if the interviewee was to remember or think of something relevant to the project.

Notes were in generally taken by the interviewer during the interview to remember key points of interest and also used during the transcription to remember particular information. During some interviews this was not done, as it seemed disturbing and/or too time consuming by the interviewer.

The transcription of all the interviews are transcribed with the focus of keeping it true to its original nature, as to not loose vital information and/or key interests told by the interviewer (Braun et al., 2006). The transcription was also checked against the audio records several times to increase the accuracy of the transcription.

4.5.2 Analysis phase

The analysis followed the guidelines of Braun and Clark, where two of the main themes were theory-driven and the last data-driven. Phase two was done by writing notes and coding each extract of transcription. The coded extracts were then sorted to give an overview and to

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27 simplify thematization. Phase three was done to group the codes found into meaningful

themes and to categorize the data. To some extent phase four and five was done

simultaneously. To review and revise the themes to either join or separate themes and to define the main themes and sub-themes presented in chapter 5. During the analysis the data material was read multiple times to ensure that overall information gathered from the informants was represented in the results (Braun et al., 2006).

4.6 Ethics

To ensure anonymity and informed consent, ethical considerations were taken pre interviews.

Information about the study and a consent form was sent to all ambulance stations in Oslo and Akershus counties (attachment II in Norwegian). Informed consent through written and verbal communication was given as to describe the purpose and procedure of the interview, and explicit consent was given by the interviewee. The information and consent letter based on the Norwegian Center for Research Data’s template included information about

confidentiality, who had access to the data, how and for how long it would be stored and the interviewee’s right to access the data regarding themselves, drop out of the study and to whom they could complain (Kvale, 1996; Norwegian Center for Research Data, 2019). The interviewees are anonymous due to that their identity is not relevant to the study, but their insights of their workday are. As the interviews were conducted in Norwegian, an

anonymizing factor was the translation to English when using quotes, and that results would be presented in more general terms i.e. grouping of viewpoints. As all the informants are ambulance personnel the quotes will stand without numeration of interview object, title or other explanation.

This research project (reference number 394413) was approved by the Norwegian Center for Research Data, NSD (attachment III in Norwegian).

Of the 22 interviews conducted, no one withdrew their consent.

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4.6.1 Validity and reliability

Validity is the extent to which the study measures what is said to be measured (Justesen et al., 2012). The concept, in this thesis, relates to the quantitative based analysis of the data, which in this study are interviews and that the findings are an accurate representation of what has been investigated. Description of data analysis and processes has been described in the above subchapters 4.1-4.5. Reliability refers to if the study’s methodology and instruments are well defined so that others, by following the same procedure would arrive to the same results (Justesen et al., 2012). In this thesis this would entail interviews as the research instruments and thematic analysis as the methodology for analyzing the data. The chosen method of qualitative research seemed to most fit the research question of the thesis with regards to gaining in-depth knowledge from the ambulance personnel. Similar for the choice of one-to- one semi-structured interviews, to enable the interviewees freedom to express their

experiences and reflections in a more open way without others present. The choice of using thematic analysis was based on feedback from the supervisor as well as that Braun and Clark presented a guide to which to undertake the analysis for people with little experience.

4.6.2 Limitations and bias

The interviews were performed in Norwegian, the language used by the ambulance personnel in their daily life. This to increase the comfort of the interviewees and to prevent loss of information due to possible language barriers. As the primary data was collected in

Norwegian and later translated to English some of the meaning and local jargon and/or slang might be lost, as well as the translators interpretation when translating (Li, 2011). To try to prevent loss of information and/or meaning, reflection and cooperation of the translations was implemented by the student and supervisor, i.e. collaboration and agreement between the student and supervisor of the translations (Fersch, 2013). While translating, focus on the overall meaning of the transcribed quotes has been emphasized rather than translating word- by-word. This to present data that are as close as possible to the original verbal quote.

Time constraint due to the deadline of the thesis limited the number of interviewees. To achieve the number of interviews in this thesis, a majority was done over telephone. During a face-to-face interview the interviewer will also receive visual information e.g. body language, facial expressions and also interact with the interviewee differently than over telephone. As

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29 both face-to-face and telephone interviews were done, the interviewer found that to be

objective and neutral was more achievable during telephone interviews than during face-to face interviews. On the other hand, face-to face interviews felt more natural, meaning that it was more like a conversation between two people, where one asked the majority of questions and controlled the topic.

Interviews as Kvale states are “an inter change of views between two persons conversing about a theme of mutual interest” (Justesen et al., 2012; Kvale, 1996). Even with a realist perspective where the researcher is to be objective and neutral, this can sometimes be difficult as an interviewer, because we can relate and are affected by what the interviewee shares (Justesen et al., 2012). To emote by laugher or other sentiment is natural, and is hard to avoid in a conversation between two people. The interviewer’s goal was to be as professional as possible, but at times found it hard not to be affected and agree with statements of the

interviewees during the interviews. In the presentation of the results this has been taking into account, and to the best of the capabilities of the researcher, to present the results as neutrally and objectively as possible.

The study sample compared with the total amount of ambulance personnel in Oslo and Akershus counties can be seen as low, due to time constraints and feasibility. The interviews could also have had a longer duration, but could have decreased the number of interviews due to time constraints for both interviewer and interviewee. Even though the sample was limited, the results show that many of the reflections and experiences were the same. By comparing the results with theory and previous research, generalization of the findings can be done to the group of ambulance personnel in Oslo and Akershus counties, and could be representative for other countries with similar arrangements (Justesen et al., 2012).

A part of this study included spending considerable time trying to read and find research and relevant documents, strategies and policy. The results of this extensive search have been presented throughout this thesis.

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5 Results

The goal of the study was to research how standby points impact the work day of ambulance personnel with regards to motivation, work environment and internal and external influences.

The results presented in this chapter are based on the interviews conducted with the informants. The results section will be organized based on the themes found during the thematic analysis. The following main themes were identified:

• Work environment

• Motivation

• Quality

Quotes will either be before or after the text of explanation with single spacing. Double spacing indicates a new result finding.

5.1 Work environment

Work environment refers to both the physical and psychological conditions at the workplace, as described in subchapter 1.1 (Arbeids- og sosialdepartementet, 2005; Jakhelln et al., 2018).

The results have therefore been divided into three sub-themes; social relations, facilities and management, to best sort the data from the interviews.

5.1.1 Social relations

Social relations refer to the social interactions between the coworkers at the station, between partners in the ambulance and the rest of the organization. This section discusses mostly the finding of the first question of the interview.

15 of the 22 informants replied that standby points had affected the social relations negatively.

Impact of standby points on the workday of ambulance personnel