Research Project

Street-level bureaucrats operate in a world relatively free of supervision, exercising discretionary abilities often without the presence of formal authority figures or managers. Although wide latitude in decision making is a norm of frontline work, leaders may occasionally be present to supervise service provision. This exploratory research employs narrative inquiry to examine the interactions of street-level personnel and formal authority figures during service provision in emergency medical services. Results indicate that occasions for compliance and disregard for managerial directives are manifest. Compliant behavior was evident when patient clinical needs were relatively clear and the effects of the directives were reasonably consistent with the paramedic s preconceived notions of appropriate action. Deviation from managerial directives was apparent when patient s positive outcomes were dependent on ignoring orders. Contributions to theory and practice, as well as avenues for future research are discussed.

Key Words: emergency medical services, street-level bureaucracy, leadership

INTRODUCTION

The demand for emergency medical services (EMS) in the United States has increased steadily since the advent of formal systems of prehospital care in the mid- twentieth century, with more than 36 million calls for service and 28 million patients transported in 2009 (Federal Interagency Committee on EMS, 2011). This volume of service interactions, when considered concomitantly with the intricacies and complexity of providing human services and the magnitude of the consequences of individual and organizational performance in EMS, calls for a need to identify and understand these interactions in greater detail and specificity.

Individuals engaged in EMS provision specifically tasked with treating and transporting patients to definitive care can be conceptualized as street-level bureaucrats (Lipsky, 1980). Past research on street-level bureaucracy has focused on several occupational areas, including law enforcement, nursing, welfare eligibility workers, and teachers (Isett, Morrissey, and Topping, 2006; Maynard-Moody and Musheno, 2003; Riccucci, 2005), on the influence of management in frontline decision making (May and Winter, 2007; Riccucci, 2005), and on concepts of leadership in street-level services (Vinzant and Crothers, 1994, 1996, 1998). These studies have established a foundation of knowledge that makes clear the importance of street-level workers in the implementation of policy, highlights the role of discretion and legitimacy in this process, and examines the relationship between frontline workers and direct supervisors. Given the substantial impact of frontline workers on actual provision of services, it is important to advance understanding of ways in which leadership and supervision can make a difference.

As with other street-level professions, EMS providers generally work in a context relatively free of formal supervision, are exposed to substantial situational complexity and contingencies, and must engage in discretionary decision-making processes with limited assistance from formal authority figures. In select cases, organizational supervisors or managers may be present to supervise direct service provision, and instances of supervisory input may result in general agreement, signaling appropriateness of rule application or adherence to professional or organizational norms, or may serve to challenge the relative autonomy of street-level EMS providers.

Considering the latter, a question naturally becomes evident: What factors may spur acquiescence with, or deviation from, supervisory directives in cases of disagreement or conflict? This exploratory research examines two cases of conflict and determines subjectively important factors that frontline EMS workers note as central in their decisions to abide by or deviate from directives. A grounded theory approach is used to examine text generated by semi-structured interviews of frontline paramedics discussing accounts of challenging or complex incidents. We first review pertinent literature on street-level bureaucracy, management of frontline employees, and emergency medical services. Next, we outline the research design and methods used to present and discuss

8 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1 Supervisor-Worker Interactions in Emergency Medical Services

two narratives of street-level EMS care. We acknowledge the limitations of the study and offer concluding thoughts, focusing on contributions to theory and practice and directions for future research.

LEADERSHIP IN STREET-LEVEL WORK

Two major streams of research have previously addressed leadership in direct service provision and are especially relevant to this question. While the first focuses on how street-level service providers may exercise discretion in a rule-saturated environment, the second perspective examines the prospects for leaders to influence street-level work.

Street-Level Public Service

Lipsky s (1980) seminal work on street-level bureaucracy defined and brought to the fore concepts of frontline public service. Two defining characteristics of street-level occupations were notable in these early discussions: face-to-face interactions with clients and the ability to exercise discretion (Handler, 1986; Lipsky, 1980). Street-level bureaucrats follow complex rule sets in uncertain and time-bound situations, all within a context of potentially ambiguous organizational goals (Keiser, 1999). Frontline personnel are critical to the success of public programs as they occupy the final step in the policy implementation process (Lipsky, 1980; Riccucci, 2005; Maynard-Moody and Musheno, 2003), and their actions in many cases have a direct impact on important quality-of-life issues for clients and, when considered cumulatively, on the outcomes of these public programs (Bovens and Zouridis, 2002; Keiser, 1999; Riccucci, 2005).

The concept of administrative discretion and constraints on behavior take center stage in this discussion of frontline workers. Hupe and Hill (2007) noted that as rules specify the duties and obligations of officials, discretion allows them freedom of action (280 281). When rules are incomplete, inappropriate, or vague, other sources of influence may be crucial in shaping the discretionary behavior (Handler, 1986; Vinzant and Crothers, 1998), including social, professional, and organizational norms, beliefs, and values (Dworkin, 1977; Hupe and Hill, 2003; Scott, 1997). Street-level service provision, then, lies at the intersection of rules, cultural expectations, and situational factors, thereby posing a flexibility versus uniformity dilemma (Loyens and Maesschalck, 2010: 67).

Research on frontline positions has found empirical support for many of these assertions. Rules are influential in shaping behavior, as are organizational and occupational culture (Isett, Morrissey, and Topping, 2006; Kelly, 1994; Sandfort, 2000; Riccucci, 2005), and extraorganizational sources of influence, including direct and indirect relationships with political principals (Gilboy, 1992; May and Winter, 2007).

April 2013 Alexander C. Henderson & Sanjay K. Pandey 9

Management and Leadership in Street-Level Work

Managerial influence on street-level bureaucrats has been examined with varying results across different occupations and organizational settings (May and Winter, 2007; Riccucci, 2005). Riccucci (2005) noted a number of distinct methods that managers may use to foster change at the frontlines of welfare agencies, including training, engaging workers in decisions about processes, providing feedback, and use of administrative interventions to encourage or discourage specific behavior (87 89). However, because managers are in many cases not present for service interactions in bottom-heavy street- level services, these activities tend to occur before or after a service interaction. In those cases in which a manager is present or engaged in decision making, the manager may serve to establish or reify what constitutes appropriate behavior.

May and Winter (2007), in a study of street-level bureaucrats implementing employment assistance reforms in Denmark, found that higher-level officials can have a substantive impact on the manner in which workers understand and implement policy (469). Although the magnitude of supervisory influence was somewhat weak, this finding serves to link the influence of superiors on street-level bureaucrats with their espoused views on policy. Attention to a specific policy by higher-level officials may promote understanding or engagement with a policy, and managers who are increasingly persuasive may exert more influence in adherence to policies.

A body of literature specifically examining street-level leadership has emerged, focusing on the leader-like qualities of street-level workers themselves (Vinzant and Crothers, 1996: 464). Frontline workers may be able to exercise substantial discretion over outcomes (reflecting a transformational leadership style), discretionary decisions about processes (reflecting a transactional or situational leadership style), or discretion over both (reflecting a combined style) (Vinzant and Crothers, 1998: 91 92). In each of their studies of police behavior, Vinzant and Crothers (1994, 1996, 1998) found evidence of the situationally contingent exercise of transactional and transformational leadership styles. Discretionary decisions about both process and outcomes were shaped by leadership from colleagues not identified as formal managers or supervisors.

Emergency Medical Services

EMS has evolved into a core public service over the last several decades (IOM, 2007: 1), and research examining the field has generally fallen into one of three categories of inquiry: clinical, educational, or systems level (NHTSA, 2001). Clinical studies examine the therapeutic and medicinal aspects of EMS, studying topics such as the efficacy of medications (McEachin, McDermott, and Swor, 2002; Reed, Synder, and Hogue, 2002). Educational research has examined the efficacy of formal training (LeBlanc et al., 2005) and experiential learning in EMS (David and Brachet, 2009). Systems-level

10 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1 Supervisor-Worker Interactions in Emergency Medical Services

investigations have studied the process of predicting call volume (Brown et al., 2007; Setzler, Saydam, and Park, 2009) and the effects of response time and service level on patient outcomes (Nichol et al., 1996; Pons and Markovchick, 2002). These studies contribute to our understanding of the service and may have a tangible impact on street- level EMS providers, yet they leave important gaps in knowledge that cut across boundaries. Thus, they fail to examine the full nature of the complex interactions among EMS personnel and patients.

METHODS

Empirical research into the unique nature of street-level bureaucrats has employed qualitative methods (Gilboy, 1992; Maynard-Moody and Musheno, 2003; Newman, Guy, and Mastracci, 2009; Sandfort, 2000; Vinzant and Crothers, 1998), mixed methods (Oberfield, 2010; Riccucci, 2005), and quantitative experimental studies (Scott, 1997). This paper serves as a preliminary investigation of influence and the exercise of discretion in frontline leader-worker interactions, topics that are both inherently subjective. Accordingly, an interpretive methodological foundation is appropriate for this study.

This exploratory research uses a narrative analysis to capture several interrelated, multifaceted, and relatively unexamined concepts as they emerge in the tangible actions of frontline EMS providers (Yin, 1994). The unit of analysis for the study is the narrative of a street-level EMS worker caring for a patient amid physical, social, and clinical contingencies. Klein, Calderwood, and Macgregor (1989) characterize such settings as “naturalistic ones [with] high time pressure, high information content, and changing conditions” (462). Our use of stories is similar to Klein (1998), who makes the astute observation that “stories [...] contain many different lessons and are useful as a form of vicarious experience for people who did not witness the incident” (179).

Participating Individuals and Organizations

EMS agencies were selected from a single state, Pennsylvania, in order to keep the political and regulatory context constant across organizations. Pennsylvania constitutes an ideal location for this research in that it has both a large number of emergency medical services providers more than 13,000 full-time, paid providers (Department of Labor, 2011) and displays a substantial call volume approximately 1.8 million calls for service in 2008 (PA BEMS, 2009: 1). The choice of EMS agencies was purposive, with the primary criteria being both high call volume and variation in organizational arrangement (e.g., fire department based EMS, police department?based EMS, and hospital-based EMS), while remaining similar in demographic and geographic

April 2013 Alexander C. Henderson & Sanjay K. Pandey 11

characteristics (West, 2001). Interviewees for this study were randomly chosen from a population of on-duty paramedics over a two- to three-day interview period for each of the three agencies. The interview process outlined below was pilot tested with paramedics from EMS agencies not involved in the formal study. Paramedics selected for participation were employed in a full-time capacity, and were primarily engaged in emergency (9-1-1) transportation services.

Semi-Structured Interviews: Narratives of Street-Level EMS

Semi-structured interviews were conducted to collect narratives of street-level EMS provision, with an emphasis on incidents that were particularly memorable, complex, or challenging. Narrative inquiry has a number of strengths for the study of frontline work (Bailey and Tilley, 2002; Connelly and Clandinin, 2006; Kelly, 1994; Maynard-Moody and Musheno, 2003) in policy analysis and implementation (Roe, 1994). Stories allow for investigation of complex interactions among a number of variables and locate these interactions within a specific context, and can move beyond simple description to “encompass the hows of people’s lives (the constructive work involved in producing order in everyday life) as well as the traditional whats (the activities of everyday life)” (emphasis in original, Fontana and Frey, 2005: 698).

The narratives included in this paper were selected for comprehensiveness, allowing for the identification of the nature of the situation, the impressions and reactions of the paramedics as they provided patient care, and the influence of supervisors who shaped paramedic behavior. Narratives were analyzed using a grounded theory approach (Charmaz, 2005; Glaser and Strauss, 1967), appropriate in that it permits exploration of data in a manner that highlights “enacted processes, made real through actions performed again and again” (emphasis in original, Charmaz, 2005: 508).

FINDINGS

Two narratives of street-level patient care are presented and discussed below, focusing in particular on instances of disagreement or conflict with supervisors and the resulting behavior of paramedics. Narratives presented here serve as important cases of response to conflict in manager-worker interactions. The first incident illustrates deference to supervisory directives, followed by a case outlining deviation.

Compliance with Directives: Paramedic Acquiescence Despite Disagreement

Paramedics routinely respond to emergencies for patients in cardiac arrest, enacting precisely defined clinical protocols as they work collaboratively to bring patients back to

12 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1 Supervisor-Worker Interactions in Emergency Medical Services

life. Noting that this first incident was abnormal, the narrator highlights the potential presence of a toxin and the associated risks that may be present for the patient and responders alike. The resulting interactions between the narrator and the supervisor illustrate tension between ideas of appropriate action, but ultimately result in deference to supervisory directives.

We had a guy outside working doing yard work. He had a lot of pesticides; just the regular stuff that you buy at Home Depot.[...] We pull up, [...] there's an older gentleman standing in the driveway and a female [...] doing CPR on a guy.[...] So I called for the supervisor because my partner was pregnant. She’s due any day now. I called for the supervisor to come give us a hand.

We worked him. I actually tried to intubate him.[...] Just got the laryngoscope in his mouth, and went to put the tube in his mouth and blood just came out everywhere. So, my supervisor, after the call was all over, the supervisor is thinking that this could have been [caused by] a pesticide, because any toxin could have started the pulmonary edema.[...] But, this was bright-red blood, so I wasn’t thinking pulmonary edema.

But, the boss, he took it his way, and we started the whole HAZMAT thing.[...] So, when it was all over with, me, my partner, the lady, my supervisor, we all had to go [...] through showers, evaluations, and the whole nine yards. I got a couple of specks of blood on me that was it for me.[...] A little bit of blood is not going to bother me as long as I know that my hands are not all chopped up. But, yeah, that was annoying. I think that was a little asinine myself. I kinda disagreed with it [...] but you have to go with the program. I wasn’t happy with it, I wasn’t happy at all. “This is [ridiculous]. Really? I gotta get [decontaminated] for what? I got a couple of specks of blood on me.” But, yeah, that really twisted me up a little bit.

I was a little perturbed. “Are you kidding me, man? Seriously? I’ve got to do all this? For what?” We had to clean the ambulance, go clean ourselves, we had to [be decontaminated], we had to be evaluated by the doctor, then had to come back, had to clean all our [equipment] up. It was your typical cardiac arrest turned into a possible pesticide poisoning.

“Really? Seriously, we gotta do this?” “Yeah.” I think his main thought process was that my partner was pregnant, nine months pregnant, this other lady did mouth-to-mouth me personally, I could have washed my hands with soap and water and been on my way back in service. My partner didn’t get messy, it was the lady who did CPR, if anybody. There [were] no blood splashes, there was no

April 2013 Alexander C. Henderson & Sanjay K. Pandey 13

offing of gases, or anything. Didn’t get [...] lightheaded, no nausea. It was your typical cardiac arrest. “Really? We gotta go do all of this?” [My supervisor] needed to cover [himself]. I guess that's just part of being a supervisor.

Upon arriving and assessing the scene, the supervisor and the narrating paramedic suspected different causes for the patient’s condition, both with different resulting treatment plans. Though the rules for treating a cardiac arrest patient are strict and proscribed, those for identifying and declaring a hazardous materials incident are less distinct, especially on a small scale as described in this incident. Noting the possible risk to the responders and the bystander who had attempted to resuscitate the patient, the supervisor made the discretionary decision to treat the scene as a hazardous materials incident. In doing so, the supervisor drew on both the clinical protocols and formal organizational authority as the foundation for his decision.

The results of the supervisor’s discretionary decision on the responding paramedics were notable. A standard incident would require only a routine clean up and restocking of the ambulance. This incident, and the supervisor’s decision to label it a hazardous materials incident, required decontamination of personnel, bystanders who rendered care, vehicles, and equipment, and a post-incident evaluation by an emergency department physician.

While indicating his displeasure with the complex and time-consuming decontamination process, the narrator also recognized the need to “go with the program.” The supervisor’s decision to treat the situation as a hazardous materials incident represented at the same time a stance that was markedly different from that of the narrator, but one that was also distinctly aimed at protecting the health and safety of the responders. The narrator also understood the need for the supervisor to “cover” himself, displaying caution in a situation imbued with risk for both patient and providers. For these reasons, the paramedic relating this story was willing to go through the extra steps required for decontamination.

Deference to a supervisor in cases of conflict was not, however, the only response to direct orders to street-level EMS providers, and examination of a case that stands in contrast to the narrative of compliance presented previously will provide a more balanced perspective.

Disregarding Directives: Paramedic Discretion and Patient Outcomes

An incident recounted by a paramedic illustrates a demonstrable conflict between a treating paramedic and a frontline supervisor in terms of individually held concepts of what constitutes appropriate care. The case below highlights the importance of situationally contingent knowledge and action in EMS, and describes measured and purposeful deviation from a supervisory directive to engage in specific patient care

14 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1 Supervisor-Worker Interactions in Emergency Medical Services

activities.

We got called to an accident up on [a four-lane roadway], and it’s a fairly busy intersection. It was a low-impact accident, and I get there and there’s a guy [...] kind of leaning over between the two seats. And he’s complaining of neck pain. So I walked up and I went to [stabilize his spine], and he tried to move his head, and I felt some grating, and I’m just like, “That’s not too good.” And during talking to him I asked him his name.[...] [He] was a physician from [a local hospital].[...] And it turns out he had a fractured [spinal vertebra]. So here’s this physician.[...] I’m assuming he knew what was going on, because he told me, “I think I might have broken my neck,” and when he tried to move a little bit, I felt the grating of it, and I’m like, “I think you did too, don’t move.” And actually [...] we wanted to fly him [via helicopter] to [a regional trauma center] because it was a spinal injury. And my boss at the time [...] shot me down for it.[...]

We’re seven minutes from trauma center by ground. And I said [to my supervisor], “Yeah, you’re right. You’re absolutely right, but we have to go down bumpy [...] streets, we have to cross trolley tracks and everything like that.” I just didn’t feel comfortable driving even though, yes, [it was] seven minutes away. And again, he wasn’t on scene to make that determination. He didn’t know what I knew.[...] We would have been going down trolley tracks the whole way.

And so we ended up flying him because I didn’t listen to what my boss said. [The patient’s] outcome was actually pretty good. He was walking around with a walker for a little bit, but then he made a full recovery. That was one of the challenging calls, I think.

The responding paramedic presenting this case realized upon a more detailed assessment of the patient’s condition that the injuries could potentially result in paralysis or death. Typically, a severely injured patient would be transported by ground to a regional trauma center, however the paramedic suspected that the patient had broken his neck, thereby complicating the transportation decision. The clinical protocols addressing the selection of the method of transporting a patient in this particular situation give wide discretionary latitude to the treating paramedic. Though criteria are established to guide this decision, the paramedic providing patient care is charged with the interpretation of policy and final decision on method of transport. This ability to make the “final call” may be further restricted within EMS agencies through the creation of organizational procedures that give authority to paramedic supervisors. This was the case in the

April 2013 Alexander C. Henderson & Sanjay K. Pandey 15

narrator’s story; though he was not on the scene of the accident, the supervisor instructed the paramedic to cancel the helicopter and transport the patient to the trauma center in the traditional manner.

Interestingly, the supervisor’s decision does not take into account the experience and judgment of the paramedic directly providing care. A less-experienced paramedic, or one who was more inclined to follow the directives of the supervisor, could have simply followed the order and risked a potentially life-altering trip down poorly surfaced roads. The narrator of this incident, however, decided to exercise his professional judgment and made a purposeful choice to call for a helicopter, a decision intended to reduce the chances of further serious injury.

Both incidents recounted here illustrate the possibility of direct supervisory input into the processes of policy implementation and patient care, and the possibility of disparate ideas of what constitutes appropriate behavior. The responses of the narrators, though, were on opposite ends of a spectrum; one incident resulted in compliance with an order, the other in deviation. Highlighting key aspects of these incidents in tandem will contribute to an improved understanding of these interactions.

DISCUSSION AND CONTRIBUTIONS

The narratives presented here reflect the complexity, uncertainty, and urgency found in many street-level EMS incidents. The need to respond to situational contingencies places stress on paramedics attempting to implement substantial yet imperfect rule sets, a situation made increasingly complex by the intervention of direct supervisors. In both incidents, paramedics were faced with a decision to act in a manner that was not fully illustrated or specified by clinical rules and, in each case, the exercise of discretion was necessary. Efforts by a supervisor to reduce discretion through direction were evident in both cases, with both supervisors indicating that specific behaviors were appropriate to the situation. In both instances, the narrator’s assessment of what would be the most appropriate action conflicted with the supervisor’s conceptualization of the appropriate action, and some amount of purposeful internal deliberation within the narrator was initiated.

In the first incident, characterized by eventual agreement with the supervisor, key considerations were focused on the possible viability and veracity of the supervisor’s conceptualization of the situation, possible harm to colleagues and bystanders, and an absence of detrimental effect to the patient. The supervisor’s proximity to the incident and knowledge of the possible effects of toxins were plausible, and thus the narrator, though somewhat unhappy with the added complexity of applying the hazmat label to the situation, acquiesced. The decision to accept the supervisor’s ruling and proceed with decontamination and physician exam was supported by the consideration of possible

16 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1 Supervisor-Worker Interactions in Emergency Medical Services

harmful effects to both the bystander who had rendered care and the narrator’s partner. In the second incident, characterized by deviation, patient need and potential patient

outcomes took center stage. The paramedic established his own conceptualization of appropriate patient treatment behavior, which was then countermanded by his supervisor. The supervisor’s distance from the incident, lack of specific situational knowledge about patient condition and clinical needs, and failure to understand possible patient outcomes that may have resulted from the directive were central. Deviation, then, was necessary to avoid exacerbating a potentially devastating condition and ensure the best possible outcome for the patient.

In both incidents a number of key factors were evident in the decision to follow or ignore the supervisor ’s directive. First, cognizance of conflict or the potential inappropriateness of a supervisor’s directive was notable, thus signaling that the paramedic’s knowledge of clinical and operational rules, and situational or local knowledge are important preconditions to the decision to follow or deviate from orders. Once conflict was evident, the supervisor’s clinical or operational expertise or credibility, as well as the supervisor’s local or situational knowledge, were important in the paramedic’s judgment of the appropriateness of the directed action. Being present at an incident and understanding the requirements of patient and scene management were key to establishing a basis for following or deviating from a directive. Finally, considerations of the potential outcomes for EMS providers, bystanders, and patients were notably important. The particular possible outcomes for each category of individual on scene were central to a decision to comply with or ignore orders.

In these instances factors such as expertise and situational knowledge for both the street-level bureaucrat and the frontline supervisor were critical in understanding both the identification of conflict and the decision to comply with, or deviate from, a supervisory directive. Given that many of these decisions are shaped through experience with particular types of situation and experiential learning, this lends support for theories of street-level bureaucracy that place emphasis on occupational culture (Isett, Morrissey, and Topping, 2006; Riccucci, 2005; Sandfort, 2000). Likewise, an understanding of the possible outcomes both for crew members and patients was crucial in understanding the decision to comply or deviate.

A number of practical considerations evident here may be of interest for future empirical research. First, in both cases communication between frontline providers and supervisors was crucial in the process of creating, or failing to create, understanding. Creating a firmer foundation for individual decision making through clearer communication could allow for reduced chance of error that may impact the safety of both crew members and patients. Second, in both cases situational knowledge was important for both frontline workers and supervisors, with increased expertise and experience potentially leading to increased trust in difficult and complex situations. Finally, the situationally specific knowledge that results from incidents like these may be

April 2013 Alexander C. Henderson & Sanjay K. Pandey 177

valuable to other paramedics after the fact. The expertise that served to potentially improve patient outcomes or ensure crew member safety in these incidents may be transferrable in post-incident debriefings or case study discussions among EMS providers.

CONCLUSION, LIMITATIONS, AND FUTURE RESEARCH

This exploratory study of leader-worker interactions in EMS represents an important area of focus for future inquiry. EMS is fundamentally different from welfare eligibility work, community policing, and other line-level functions, thus bringing to the fore considerations for leadership on the part of managers and supervisors in the profession. Though definitive conclusions about these interactions cannot emerge from the discussion of these narratives, the findings presented here do indicate that this is an emerging area of inquiry. Formal leaders in EMS should consider both the expertise and intentions of EMS providers as they engage in service provision, acknowledging that the situationally contingent use of discretion may be critically important to patients and can be construed as leadership in and of itself (Vinzant and Crothers, 1998). The results of managing for compliance versus managing for outcomes may be tremendously different, and the implications for individual patients may be great.

A number of limitations of this research are notable. First, this article reports only two service interactions illustrating conflict in manager-worker relations, a number that is not representative of a full body of these interactions or incidents in street-level EMS. Related to this, this research only considers the interactions of street-level workers and their direct supervisors during emergency incidents, and does not consider interactions outside of emergency incidents. Though necessary for the purpose of this study, selection of participating agencies and paramedics was not random, thus allowing for possible biases. Finally, although well suited for this study, the stories presented here are not objective fact, but rather individually constructed interpretations of events (Maynard- Moody and Musheno, 2003: 26). Indeed, the stories presented by participating subjects may only represent cases that the participants deem to be acceptable for presentation (Maynard-Moody and Musheno, 2003: 32). As this study is exploratory in nature, these limitations are acceptable.

Future research should extend, refine, or challenge the stories in this study, focusing on narratives that support or run counter to those found here. Other means of collecting data, including direct observation of incidents or participant observation with follow-up interviews, should be considered to provide a more robust idea of the causal relationships at work. Likewise, examination of interactions with other individuals with legal authority to provide direction should be pursued, with a specific focus on the physicians who staff emergency departments and provide clinical guidance to paramedics operating in the

18 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1 Supervisor-Worker Interactions in Emergency Medical Services

field. The examination of public, private, and nonprofit services located in urban, suburban, and rural contexts is also important, as is the study of EMS personnel with varying levels of training and experience.

This exploratory work can serve as a call for more focused examination of this important area of public service. Continued refinement and reevaluation of our understanding of the interactions between street-level EMS workers and leaders in EMS is crucial given the critical nature of this core public service.

REFERENCES

Bailey, Patricia H., and Stephen Tilley. 2002. Storytelling and the Interpretation of Meaning in Qualitative Research. Journal of Advanced Nursing 38(6): 574-583.

Brown, Lawrence H., E. Brooke Lerner, Baxter Larmon, Todd LeGassick, and Michael Taigman. 2007. Are EMS Call Volume Predictions Based on Demand Pattern Analysis Accurate? Prehospital Emergency Care 11(2): 199-203.

Charmaz, Kathy C. 2006. Constructing Grounded Theory. London: Sage Publications.

______. 2005. Grounded Theory in the 21st Century. In Handbook of Qualitative Research Methods (3rd Ed.), edited by Norman K. Denzin and Yvonne S. Lincoln. Thousand Oaks CA: Sage Publications, Inc.

Connelly, F. Michael, and D. Jean Clandinin. 2006. On Narrative Method, Personal Philosophy, and Narrative Unities in the Story of Teaching. Journal of Research in Science Teaching 23(4): 293-310.

David, Guy, and Tanguy Brachet. 2009. Retention, Learning By Doing, and Performance in Emergency Medical Services. Health Research and Educational Trust 44(3): 902- 925.

David, Guy, and Scott E. Harrington. 2010. Population Density and Racial Differences in the Performance of Emergency Medical Services. Journal of Health Economics 29(4): 603-615.

Department of Labor (2011). Occupational Employment and Wages, May 2011. Retrieved May 9, 2012 from: http://www.bls.gov/oes/current/oes292041.htm

Dworkin, Robert. 1977. Taking Right Seriously. Cambridge, MA: Harvard University Press.

Federal Interagency Committee for Emergency Medical Services (2011). National EMS Assessment. Retrieved February 28, 2012 from: http://www.ems.gov/pdf/2011/

April 2013 Alexander C. Henderson & Sanjay K. Pandey 19

National_EMS_Assessment_Final_Draft_12202011.pdf

Fontana, Andrea, and James H. Frey. 2005. The Interview: From Neutral Stance to Political Involvement. In Handbook of Qualitative Research Methods, edited by Norman K. Denzin & Yvonna S. Lincoln. Thousand Oaks CA: Sage Publications.

Gilboy, Janet A. 1992. Penetrability of Administrative Systems: Political “Casework” and Immigration Inspections. Law & Society Review 26(2): 273-314.

Glaser, Barney, and Anselm Strauss. 1967. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, IL: Aldine.

Handler, Joel F. 1986. The Conditions of Discretion: Autonomy, Continuity, Bureaucracy. New York, NY: Russell Sage Foundation.

Hill, Michael, and Peter Hupe. 2003. The Multi-Layer Problem in Implementation Research. Public Management Review 5(4): 471-490.

Hupe, Peter, and Michael Hill. 2007. Street-Level Bureaucracy and Public Accountability. Public Administration 85(2): 279-299.

Institute of Medicine. 2007. Emergency Medical Services: At the Crossroads. Washington, D.C.: The National Academies Press. http://books.nap.edu/ openbook.php?record_id=11629 [accessed October 27, 2009].

Isett, Kimberly R., Joseph P. Morrissey, and Sharon Topping. 2006. Systems Ideologies and Street-Level Bureaucrats: Policy Change and Perceptions of Quality in a Behavioral Health Care System. Public Administration Review 66(2): 217-227.

Keiser, Lael R. 1999. State Bureaucratic Discretion and the Administration of Social Welfare Programs: The Case of Social Security Disability. Journal of Public Administration Research and Theory 9(1): 87-106.

Kelly, Marisa. 1994. Theories of Justice and Street-Level Discretion. Journal of Public Administration Research and Theory 4(2): 119-140.

Klein, Gary A. 1998. Sources of power: How People Make Decisions. Boston, MA: The MIT Press.

Klein, Gary A., Roberta Calderwood, and Donald Macgregor. 1989. Critical Decision Method for Eliciting Knowledge. Systems, Man and Cybernetics, IEEE Transactions on 19(3): 462-472.

LeBlanc, Vicki R., Russell D. MacDonald, Brad McArthur, Kevin King, and Tom Lepine. 2005. Paramedic Performance in Calculating Drug Dosages Following Stressful Scenarios in a Human Patient Simulator. Prehospital Emergency Care 9(4): 39-444.

20 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1 Supervisor-Worker Interactions in Emergency Medical Services

Lightner, Liz, Jeremy Brywczynski, Jared McKinney, and Corey M. Slovis. 2010. Shortness of Breath: Prehospital Treatment of Respiratory Distress. Journal of Emergency Medical Services 35(4): 57-61.

Lipsky, Michael. 1980. Street-Level Bureaucracy: Dilemmas of the Individual In Public Services. NY: Russell Sage Foundation.

Loyens, Kim, and Jeroen Maesschalck. 2010. Toward a Theoretical Framework for Ethical Decision Making of Street-Level Bureaucracy: Existing Models Reconsidered. Administration & Society 42(1): 66-97.

May, Peter J., and Søren C. Winter. 2007. Politicians, Managers, and Street-Level Bureaucrats: Influences on Policy Implementation. Journal of Public Administration Research and Theory 19(3): 453-476.

Maynard-Moody, Steven, and Michael Musheno. 2003. Cops, Teachers, Counselors: Stories from the Front-Lines Of Public Service. Ann Arbor, MI: The University of Michigan Press.

McEachin, Christine C., Joseph T. McDermott, and Robert Swor. 2002. Few Emergency Medical Services Patients with Lower-Extremity Fractures Receive Prehospital Analgesia. Prehospital Emergency Care 6: 406-410.

National Association of State Emergency Medical Services Officials. 2011. 2011 National EMS Assessment. http://ems.gov/pdf/2011/National_EMS_Assessment_ Final_Draft_12202011.pdf [accessed February 10, 2012].

National Highway Traffic Safety Administration. 2001. National EMS Research Agenda. http://www.nhtsa.gov/people/injury/ems/ems-agenda/EMSResearchAgenda.pdf [accessed October 28, 2009].

Newman, Meredith A., Mary E. Guy, M.E., & Sharon H. Mastracci. 2009. Beyond Cognition: Affective Leadership and Emotional Labor. Public Administration Review 69(1): 7-19.

Nichol, Graham, Allan S. Detsky, Ian G. Stiell, Keith O’Rourke, George Wills, and Andraes Laupacis. 1996. Effectiveness of Emergency Medical Services For Victims of Out-Of-Hospital Cardiac Arrest: A Metaanalysis. Annals of Emergency Medicine 27: 700-710.

Oberfield, Zachary A. 2010. Rule Following and Discretion at Government’s Frontlines: Continuity and Change During Organizational Socialization. Journal of Public Administration Research and Theory 20(4): 735-755.

Pons, Peter T., and Vincent J. Markovchick. 2002. Eight Minutes or Less: Does the Ambulance Response Time Guideline Impact Trauma Patient Outcome? The

April 2013 Alexander C. Henderson & Sanjay K. Pandey 21

Journal of Emergency Medicine 23(1): 43-48.

Reed, David B., Gwendolyn G. Snyder, and Troy D. Hogue. 2002. Regional EMS Experience with Etomidate For Facilitated Intubation. Prehospital Emergency Care 6(1): 50-53.

Riccucci, Norma M. 2005. How Management Matters: Street-Level Bureaucrats and Welfare Reform. Washington, D.C.: Georgetown University Press.

Sandfort, Jodi R. 2000. Moving Beyond Discretion and Outcomes: Examining Public Management from the Front Lines of the Welfare System. Journal of Public Administration Research and Theory 10(4): 729-756.

Scott, Patrick G. 1997. Assessing Determinants of Bureaucratic Discretion: An Experiment in Street-Level Decision-Making. Journal of Public Administration Research and Theory 7(1): 35-57.

Setzler, Hubert, Cern Saydam, and Sungjune Park. 2009. EMS Call Volume Predictions: A Comparative Study. Computers & Operations Research 36(6): 1983-1851.

Vinzant, Janet C., and Lane Crothers. 1998. Street-Level Leadership: Discretion and Legitimacy in the Front-Line Public Service. Washington, D.C.: Georgetown University Press.

______. 1996. Street-Level Leadership: Rethinking The Role Of Public Servants in Contemporary Governance. American Review of Public Administration 26(4): 457- 475.

______. 1994. Street-Level Leadership: The Role of Patrol Officers In Community Policing. Criminal Justice Review 19(2): 189-211.

West, Elizabeth. 2001. Management Matters: The Link Between Hospital Organisation and Quality of Patient Care. Quality in Health Care 10: 40-48.

Yin, Robert K. 1994. Case Study Research: Design and Methods (2nd Ed.). Thousand Oaks, CA: Sage Publications.

Alexander C. Henderson is an assistant professor in the Department of Health Care and Public Administration at Long Island University. He holds a PhD in public administration from Rutgers University-Newark, and previously served as a chief administrative officer, operational officer, and board member for several emergency services organizations in suburban Philadelphia. Email: alexander.henderson@liu.edu

Sanjay K. Pandey is a professor in the School of Public Affairs and Administration at

22 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1 Supervisor-Worker Interactions in Emergency Medical Services

Rutgers, The State University of New Jersey, Newark. His research interests are in public management and health policy. Email: skpandey@newark.rutgers.edu

Received:

April 2013 Alexander C. Henderson & Sanjay K. Pandey 3 23

View publication statsView publication stats

https://www.researchgate.net/publication/283987859