This article traces the evolution of the ideological construction of elite multilingualism, with a focus on the values accorded to French and English, under transforming socioeconomic and institutional conditions at the International Committee of the Red Cross (ICRC). The ICRC, a major humanitarian agency based in Geneva, opens a window onto the construction of “internationalisation” and its accompanying language ideologies, resulting in fluctuating hiring requirements for “delegates” (expatriate representatives). The data include job advertisements for delegate posts from 1989 to 2020 complemented by interviews with different generations of delegates and ethnographic fieldwork in a recruitment fair. The analysis of language ideological debates at the ICRC illuminates the articulations and tensions between “roots” in Geneva, symbolised by French, and “routes” in its delegations worldwide, with English as a lingua franca, in dominant discourses about multilingualism. The requirements for ICRC delegates include English as a must and at least a second ICRC working language. Concerning the latter, there are tensions between the desired language regime at headquarters, privileging French as the “parent” language, and the current needs in key operations, with a shortage of Arabic speakers. The analysis shows that French requirements for generalist delegates have fluctuated from perfect command and good knowledge to an optional second working language. In the 2020 recruitment campaign, elite multilingualism is hierarchically stratified into English as a global language, other “working languages” including Arabic, and non-European languages such as Pashto or Dari as newly-introduced “assets”. There has been a dramatic, uh, Anglosaxonisation of the ICRC [International Committee of the Red Cross], especially headquarters, over the past ten years. Amazing! We have transformed into, uh, we have transformed our i- identity of uh- Swiss-French uh- based uh, organisation, into a truly international one, a bit like the UN, where English is really lingua franca, and French is, definitely second, second one.  Gerard is a middle manager based at the International Committee of the Red Cross (ICRC henceforth) headquarters in Geneva. As we can see in the opening quotation, he links changes in language use in Geneva to socioeconomic transformations linked to becoming “truly international”. When he joined the ICRC at the turn of the century, he had to follow a three-week induction course in French despite his limited competences. In our interview, he claims that he was recruited because there were not enough candidates and because of his fluency in another working language needed in operations. He recalls that meetings in Geneva were “still in French” in 2007 whereas “now they’re all English”. Above, he makes a connection between the increased importance of English as lingua franca, to the detriment of French as a parent language at headquarters, and the institutional transformation of the ICRC from a Swiss organisation to an international one. This transformation was initiated after the opening of “delegate” (expat representative) posts to non-Swiss nationals in December 1992, informally known as “internationalisation” among delegates. The ICRC is caught in the tensions surrounding English as a dominant lingua franca vis-à-vis the traditional parent language in the organisation’s headquarters, documented in multinationals  international organisations. Thus, this process emphasises enhanced collaborations with local partner associations and improved communication with beneficiaries, but pays little attention to language in institutional policies  is a humanitarian organisation with roots in Geneva and routes spanning to over 80 countries. It is legally constituted as an association under Swiss law with an international mandate based on the Geneva Conventions since 1864. Its mission includes protection activities , assistance to the affected populations  and prevention  in emergencies and armed conflicts. It is primarily funded by voluntary contributions from wealthy signatories to the Geneva Conventions (around 80–85% of its budget), especially the United States and the Swiss Confederation , the ICRC was founded in Geneva in 1863 by the local Protestant upper classes following Henri Dunant’s initiative to assist wounded soldiers after witnessing the Solferino battle  and multilingualism are central pillars in the construction of “International Geneva” as a humanitarian hub. At a federal level, Switzerland has been constructed as “an exception” to homogenising, monolingual European nation-states because it is presented as a nation created out of the will of different linguistic and cultural groups to live together. This argument was used in 1919 by Lord Robert Cecil, leading architect of the League of Nations, to support Geneva for its headquarters as proof of Swiss “absolute neutrality”. Despite federal multilingualism, the vast majority of cantons and municipalities are officially monolingual. The city of Geneva is officially Francophone while it is home to people from all over the world, many working for international organisations. There are tensions between the city’s Francophone identity, anchored in its Protestant history and roots, and the emerging multilingualism, connected with international organisations and their mobile employees.Swissness to promote its efforts , which obtained a negative vote, and Switzerland’s later entry into the United Nations in 2002 Julier, . Today, A major process that decoupled the ICRC from the Swiss Confederation was the opening of “delegate” positions to international candidates in 1992, which had been reserved for Swiss nationals to ensure their neutrality during the Cold War period . Concerning the international workforce, he later declared that “a Swiss candidate does not always fit the bill” in global recruitment campaigns in which their “main problem concerns languages”, with only 12% of staff speaking English and French . , and which ones are required for “delegate” posts in a changing institutional and socioeconomic landscape. This construction of multilingualism for humanitarian work forms the basis for language policy entextualised in artefacts like recruitment campaigns with linguistic requirements and “assets”. Put differently, elite multilingualism mediates the relationship between the institutional value of “languages”, as named objects that are tested and certified as technical skills, and access to employment as an ICRC “delegate” and its promise of career advancement. The definition and measurement of elite multilingualism, typically including two or more internationally useful languages, becomes a terrain for exclusion and distinction. Elite multilingualism is thus multi-layered, as it is rather hierarchical and ideologically loaded in a given context.These language ideologies define a certain form of multilingualism required from this elite minority of humanitarians that is suitable for routes (field delegations), through universally-accessible lingua francas like English, and roots (headquarters), indexed by French as the authentic parent language. These language ideologies link certain languages with an idealised “delegate” persona ready to navigate routes and represent roots. Language ideological debates define who gets access to this coveted post through a required form of scaling  maintains that language policies serve or undermine given socio-political, economic and institutional interests. This approach is thus concerned with language ideologies that institutionalise certain language varieties with material and symbolic consequences for social actors. Blommaert . In 2016, I observed a recruitment fair in Lausanne targeting Swiss university graduates. All the informants’ names in this article are pseudonyms and their identities have been anonymised to the greatest extent possible. In parallel, I have compiled a corpus of job advertisements and recruitment materials (1989–2020) from the ICRC library and webpage.In the analysis below, I will weave these historiographic and ethnographic data to trace the evolution of language ideological debates since the 1992 opening of “delegate” positions to non-Swiss nationals. Through a critical lens, the fluctuating construction of strategic multilingualism over time will be linked to language debates and policies in an institutional context marked by “internationalisation”.Based on major institutional developments in the HR management of delegates, I have traced the continuities and ruptures in language ideological debates on the role of French in relation to English and in the construction of elite multilingualism for delegates. First, I will link the gradual opening of “delegate” posts to non-Swiss candidates in the 1990s—known as “internationalisation” among delegates and managers until today—with the continued hiring requirements of French and English and an increasing interest in other “working languages” for new routes. Second, I will show that the increasing number of international delegates at the turn of the century sparked a debate about “Anglosaxonisation” as a threat to linguistic diversity and French in Geneva, revealing tensions between routes and roots. Meanwhile, academics, HR and some delegates were concerned with the ICRC delegate’s “Western” profile and called for more heterogeneous profiles, especially Arabic speakers for new operations. Last, I will scrutinise the multilingual turn embedded in the single global workforce framework, which I understand as the latest stage of “internationalisation”. Since 2016, recruitment campaigns construct an English-centric, hierarchical model of multilingualism including more non-European languages as “assets” for routes and relaxing French requirements in a gradual detachment from the roots, the latter engendering criticism in Geneva.Let us go back to the institutional roots. Before 1992, ICRC delegates were recruited from a Swiss national pool of university graduates for a generalist profile. In 1989, a recruitment leaflet for “delegates” . This marks the onset of tensions between roots and routes in institutional debates and decisions over the role of French. The leaflet above Figure  was reviThe main differences between these two leaflets show the transition from a Swiss to an international pool of recruitment of candidates with a similar profile to that required in 1989. In 1993, the recruitment division established its official position vis-à-vis the opening of “delegate” posts to non-Swiss delegates: it would primarily recruit Red Cross/Red Crescent National Society collaborators with over 36 months of field experience and who conformed to shared values. However, direct recruitment of non-Swiss delegates without ICRC field experience took off in 1995 out of pragmatic needs Julier, : 43 becaIn addition to debates on nationality, which language ideological debates emerged in this period of “internationalisation” understood as the opening to a global labour market? Paul, a Swiss Francophone who was a delegate from 1979 to 2010, recalled that language competences other than basic skills in English were not required when he was recruited (see Excerpt 1 below). He termed it a “second language” (lines 8–9) without specifying a first language at the ICRC, thus taking French as the (authentic) ICRC language for granted. When I asked about French (line 10), he explained that it was required or highly recommended for those who wanted to eventually work at headquarters (lines 11–12), where French was primarily used and he claimed that it is “logical” to be able to speak French in Geneva (line 21). Paul clarified that the ICRC delegates concerned would be Swiss Germans and English speakers during that period (lines 17–19), which shows a mix of Swiss and international candidates. Paul stated that English was gradually used as a working language in Geneva throughout the 1990s (lines 24–25), a decade earlier than in Gerard’s account. Therefore, he constructed a dichotomy between French as the local language “from somewhere” i.e. Geneva, highly recommended for career advancement, and English as an international language “from nowhere”, a must for missions since the early days of the recruitment division. Paul constructed two coexisting centres of linguistic authority, the taken-for-granted local (Geneva) linked to authenticity and the international (field missions) indexed by anonymous English, without any mention of other valuable languages.Excerpt 1. Interview with Paul, retired delegate. 03-02-2016.Despite the increasing use of English at headquarters (see Excerpt 1), the gradual opening to non-Swiss nationals and the dominance of Swiss delegates translated into a maintenance of French as an internal language for training and recruitment in the 1990s and beyond, according to Gerard. For example, Carolyn, a Swiss German who was recruited as a delegate in the early 1990s, moved to Lausanne to improve her French before the ICRC induction course at her own initiative.In the 1990s, elite multilingualism at the ICRC centred on English- French bilingualism with some international languages, notably Spanish, as “assets” for humanitarian routes. The gradual opening of “delegate” posts involved a gradual shift from the national (Swiss) scale towards a European scale owing to French requirements and “acceptable” nationalities for neutral representation. This process triggered institutional debates about the ICRC’s Francophone roots in this expansion for new routes, as we shall see next.The “internationalisation” process at the ICRC, initially understood as the gradual opening to non-Swiss delegates in the 1990s, was depicted to have mainly benefitted “Westerners” (left undefined) because HR targeted Western pools and institutions Julier, : 6. For Excerpt 2. Interview with Swiss delegate. Source: Julier : 104.the maintenance of French, alongside English, clearly inscribes itself in the heritage and the cultural identity of the ICRC, which has its roots and its headquarters in a Francophone city. The adoption of English as the only working language would not be a cultural enrichment (my translation).la Francophonie against the perceived Anglo-American imperialism and linguistic homogenisation of the world . Multilingualism (“other useful languages”) was not defined and was probably restricted to the list of major world languages on the 1997 brochure . Thus, the desired “delegate” in the early 2000s had a similar linguistic profile to that of the nineties but French requirements were actually relaxed, contrary to the 2003 institutional decision to strengthen its role. This leaflet explained that interpreters/translators use English as a pivotal language. Communication delegates were subject to the same linguistic requirements as generalist delegates because they had to carry out one mission as a generalist delegate before joining the specialised Communications pool. In 2012, this specialised pool targeted a language-specific Arabic profile owing to the shortage of Arabic speakers for the on-going MENA operations (see Excerpt 3). In this case, French is not required for employment but it is connected with career progression as an administrative language linked to headquarters in Francophone Switzerland. Arabic is useful with interlocutors in MENA but it does not constitute an asset for management positions and missions outside the region , sent by one of my informants.Excellent command of Arabic and English. In addition, a good command of French is a distinct asset for career development within the ICRC, as French is an institutional language.Overall, the recruitment campaigns analysed in this section suggest a relaxation of French competences for delegates despite the 2003 policy that makes it equivalent to English as an administrative language. This was partly due to the difficulties in recruiting multilingual delegates with French competences in an expanding international pool of candidates, especially those who speak “strategic” languages needed in the field. Prior to 2012, French was a deal breaker for qualified Arabic-speaking communicators. Alex was one of the delegates who replied to the job advertisement for Arabic-speaking communication delegates (Excerpt 3 above). In his early thirties, Alex held a BA and MA from the American University of Beirut. Upon graduation in 2006, he wanted to apply to the ICRC but he was officially told that he needed to speak French. He was “pissed off”, in his own words, and he took French courses at a cultural centre. Before joining the ICRC, he had worked for UN agencies, other NGOs and news media. He was recruited as an Arabic-speaking communicator after French was no longer a “big requirement” .Excerpt 4. Interview with Alex, 22-02-2017.In Excerpt 4 above, Alex links French to “culture” in Francophone Switzerland and Geneva (lines 9–11), in line with authenticity ideologies, and to a specific group of expats: Swiss Francophones who feel more relaxed in French (line 13). He categorises French as not only “from somewhere”, like Paul, but owned by a specific group to which he and his colleague do not belong (lines 13–14), the authentic Swiss Francophone delegates. In Alex’s account, French is presented as a terrain for exclusion and local distinction. This contrasts with the top-down policy change that he describes, which constructs an elite multilingualism centred on the languages spoken in MENA operations, namely English as an international lingua franca  and Arabic as a regional lingua franca for external communications, instead of French as an administrative language orienting to Geneva as a local centre of authority.For another Arabic-speaking communicator, Adam, French was also a deal breaker for employment at the ICRC despite his previous humanitarian experience. To improve his French, he requested a Francophone mission with a UN agency. Once he became a delegate, Adam did not use it for communications work at the ICRC, where English was the internal lingua franca, as explained above. Nonetheless, his Swiss manager preferred French to better express himself and to have confidential conversations, mainly with other Francophone Swiss, which corroborates Alex’s account above. Adam claimed that French is an “added value” and internal language for the Swiss managers because it “helps to- to maintain the communication channels, you know, help the colleagues to, u:h, express themselves better or just basically, you know, it’s a language to use when you don’t want anyone to understand” . Therefore, the need for Arabic speakers in key MENA operations coexisted, not without tensions, with the maintenance of French as an administrative “headquarters” language explicitly required for management posts historically occupied by Swiss delegates and informally used for internal, even confidential, communication among this population.At a crossroads between authenticity and anonymity, multi-layered elite multilingualism increasingly oriented to new regional centres of linguistic authority besides Francophone Geneva and the Anglo-centric humanitarian sector. There were also fluctuations in the relative value accorded to different working languages in terms of roots or routes.Organisation International de la Francophonie, the Canadian Embassy and the ICRC. This event tapped onto the traditional pool for ICRC delegates: Swiss university graduates in the Francophone region. My conversation with two recruiters at the ICRC stand, in my role as a researcher, confirmed the centrality of French for new candidates (see Excerpt 5 below). Despite my fluency in French, my racialised embodiment and my foreign accent in French might have motivated the recruiters’ choice of English.In April 2016, I attended an “international career day” in Lausanne, co-organised by the Swiss Confederation, targeting recent university graduates. The participating institutions included over 50 UN and international organisations. All the materials, presentations and my own conversations were in English, with the marked exceptions of the Excerpt 5. Fieldnotes from International Career Day, 14-04-2016.They speak to me in English and I introduce myself and my study on recruitment criteria for the ICRC. The younger one starts telling me what is required to work for the ICRC: […] languages spoken should include English and one of the “languages of interest” but the senior recruiter says that preferably French, because “we have neglected French for a long time”. […] This experienced recruiter tells me that French is very important for mobility because they have delegates who don’t speak French and who cannot be assigned to Francophone missions in Africa. This complicates rotations of international staff. Besides, he categorically claims that “nobody can make a humanitarian career without French because you cannot advance”. When I ask if it is related to the fact that the ICRC has its headquarters in Geneva, he insists that it is not because of that but because of field postings.The more experienced recruiter defined a “language of interest” as preferably French, which according to him had been neglected institutionally (see Excerpt 5). Unlike delegates in earlier decades (see Excerpts 2 and 4), he did not align with ideologies of authenticity linked to the ICRC’s roots in Geneva. Instead, he focused on the shortage of Francophone delegates to deploy in former French colonies in Africa. This argument was also advanced by the Médecins sans Frontières representative at the Fair. The recruiter constructed French as an anonymous language for instrumental communication in a larger region and rejected its framing as an authentic language associated with a local scale. This discursive shift constitutes a scale jump in a multi-layered multilingualism in which working languages such as French and Arabic are linked to a regional scale whereas English is a must-have lingua franca linked to a global scale, as in other international organisations.During the ICRC presentation at this event, the only one in French with accompanying slides in English, the experienced recruiter explained that it was important to speak English “quite well” and he also pointed out that French and other “languages of interest” were needed, in a descending hierarchical order. This is the case because the ICRC, unlike other organisations, does not have any implementing partners in the field and only collaborates with Red Cross/Red Crescent national societies. According to the recruiter, “languages become important because we are closer to the population” . The slides strengthened these requirements: “Excellent English and French + other languages an asset”, thus putting the two administrative languages on an equal footing as requirements. In contrast, the UN professional and higher categories require “excellent command of either English or French” and “knowledge of an additional language is an asset but not required for most jobs” . Languages other than English or French are non-compulsory “assets” to obtain these prestigious positions in a hierarchical construction of multilingualism.In May 2016, the ICRC advertised new “delegate” positions to work in the field. The job advertisement . Out of this campaign, the ICRC could not recruit enough Arabic speakers for on-going operations and as a result, a new recruitment campaign for “Arabic-speaking delegates” was launched in November 2016. It advertised the same profile with different linguistic requirements: “Fluent in Arabic and English, with a working knowledge of either French, Spanish or Russian” . The fluctuating value accorded to French as a working language linked to a world region (West Africa), on par with other working languages such as Spanish, coexists with its institutional role as administrative language linked to Geneva, which was erased in this later campaign. The requirement for fluency in both English and French was abandoned, like in previous campaigns (see Excerpt 4), based on the connection between English and a global scale, as a lingua franca “from nowhere”. These different recruitment campaigns primarily orient to different centres of linguistic authority within the organisation, i.e. MENA operations and Geneva headquarters, with different linguistic regimes and needs.There are tensions over the importance of French for the new ICRC generations, linked to the issues of career advancement and fluctuating needs in the field, with many key operations in regions where Arabic is lingua franca and an array of Francophone missions in Africa. The compromises on the role of French to recruit suitable profiles, resulting in the use of English as lingua franca, have left many unhappy at headquarters. They mobilise the discourse of “diversity”, rather than origins and tradition, in favour of French. When I first met one of my informants at headquarters, this young Francophone complained the ICRC was becoming “monolingual in English” because more and more employees spoke but English, which he opposed to widespread French–English bilingualism in the 1990s when “the effort of opening up to different languages and cultures” had succeeded .In 2017, the brochure “Working for the ICRC”—first published in 2012—was re-edited and translated into Arabic, Spanish, Chinese and Portuguese, while the first edition had been only available in English (see previous section). This decision to translate it into “regional languages” of strategic interest might respond to a gradual broadening of the recruitment pools outside Switzerland and Europe, in line with the delocalisation of some services like IT, translation and finance. There were also some crucial HR transformations towards a unified system of posts and salaries for a single, global workforce, which were enforced in 2018 . Within this unified staffing framework, the 2020 recruitment campaign states that generalist delegates “are fluent in English and two of the following languages: Arabic, Russian, French, Spanish”. This gives more importance to English and demotes the role of French as an administrative language, now likened to other “working languages” (see Excerpt 6). Non-European regional linguas francas (Dari/Pashto or Hausa) are specifically defined as an “asset” for the first time. This timidly broadens the construction of multilingualism based on strategic needs in the field.Fluent command of English and one other ICRC working language: French, Arabic, Russian or Spanish. Knowledge of a third ICRC language or any other language of interest  as an asset.Excerpt 6 constructs a multi-layered elite multilingualism to access these prestigious posts as expatriate humanitarians. On top we find English as the sine qua non for routes linked to a global scale and ideologies of anonymity, followed by “working languages” such as Arabic and French for broader communication in world regions, but which might still be heard as “voices from somewhere” linked to centres of authority like Geneva or Beirut  The question today is how to diversify international and multilingual profiles against the background of an on-going language ideological debate about the status of English and French and the practical need for Arabic. The incipient delocalisation of services and the staffing system for a unified global workforce, emphasising routes, will be pitted against the symbolic and pragmatic centrality of the Geneva roots in the years to come. Yves Daccord, Director-General of the ICRC until March 2020, has insisted on the centrality of Geneva on several occasions (see above). The nomination of Robert Mardini, of Lebanese origins and settled in Switzerland, as his replacement in April 2020 was welcomed in the Genevese press: “Speaking Arabic, he has an important advantage when we know that 70% of ICRC operations are located in the Muslim world” Bussard, . TogetheBased on archival and ethnographic data, this article has articulated major institutional transformations, gradually re-orienting the ICRC from its Geneva roots to expanding humanitarian routes, with on-going language ideological debates over the role of French vis-à-vis English and the resulting language requirements for delegates from 1989 to 2020. Overall, the meaning of “internationalisation” has been contested and re-signified by delegates and managers at headquarters. It has been closely associated with scale shifts from gradual Europeanisation via Swiss-like, Francophone profiles to a practical need for “deswesternisation” (2000s) and a “global workforce” (2016–2020) for humanitarian missions. These scale shifts have broadened elite multilingualism for delegates: besides English as the unquestioned global language, the ICRC has multiplied the required “working languages” on a regional scale and has recently diversified the “languages of interest” to non-European lingua francas as “assets”. Meanwhile, French as the “parent language” has been likened to any other working language for routes, detaching it from the ideological basis of authenticity, but it simultaneously remains an administrative language closely associated with managerial posts and headquarters.Initially, “internationalisation” was a shorthand for the gradual opening of “delegate” positions to non-Swiss nationals in 1992 in institutional and academic accounts. On an “international” market, English–French bilingualism established a continuity with the earlier Swiss profile. Throughout the 1990s, there were two coexisting centres of authority, Geneva headquarters representing an authentic voice through French, and the global humanitarian field, favouring English as a lingua franca for everybody. At the turn of the century, there were increasing numbers of non-Swiss delegates with a similar “Western” (linguistic) profile. Swiss delegates and managers discursively linked “internationalisation” with discourses of “Anglosaxonisation” opposed to the maintenance of “diversity” at headquarters, indexed by French on a local scale. During the 2000s, there were also calls for “dewesternisation”, i.e. recruiting profiles which were not Swiss-like in terms of linguistic repertoires, education and experiences, in institutional and academic circles. Despite the institutional designation of French as an administrative language equal to English (2003), the relaxation of French requirements coincided with the emergence of Arabic as a sought-after resource for key operations. Elite multilingualism was reduced to English and fluctuating competences in French with a third working  language as an asset.la Francophonie and the Arabic-speaking world respectively. Recent recruitment campaigns construct English-centric multilingualism linked to the figure of the delegate, now called “mobile staff”, foregrounding the importance of mobility and routes at the ICRC. French has been likened to any other second “working” language for mobility to certain regions, while new “languages of interest” include non-European lingua francas like Dari or Pashto as a bottom layer. This broadening of multilingualism linked to routes clashes with on-going discourses of English as a threat to “diversity” in Geneva.Recent campaigns mark a multilingual turn embedded in a HR “global workforce” project, seeking to transcend the European/Western scale as an organisation. In 2016, generalist delegates were required to be trilingual in two campaigns orienting to different regional centres of authority, “Internationalisation” is understood differently not only at particular times but also by particular social actors that (re)produce different grand narratives identified by Brühwiler et al. . The “trHiring requirements at this humanitarian organisation construct different sets of oppositions orienting to multiple centres of linguistic authority. This paints a more complex, layered and shifting picture of elite multilingualism than in the on-going debates on the institutional role of French vis-à-vis English. For HR, English has been a must-have language since 1989, as an emblem for international humanitarian routes. It contrasts with the “parent” language, French, and other working languages, which are connected with specific regional scales. In turn, HR recruiters have re-scaled French as an authentic index of institutional roots in Geneva to a regional language for mobility in missions, linked to anonymity. Both coexist, as French remains advantageous to work at headquarters unlike other working languages like Arabic (see Excerpt 3). Among the ICRC’s working languages, whose list resembles that of UN official languages, Arabic stands out because of the on-going MENA operations. Although working languages other than English have equal status in the latest recruitment campaign, their fluctuating value linked to operational needs explains the erasure of Chinese in my data. In order to increase the agency’s impact and adaptation to missions, strategic multilingualism has been extended to major regional lingua francas like Hausa and Pashto, thus “dewesternising” elite multilingualism even though they are still “assets” at the bottom layer of this English-centred multilingualism. The tensions between roots and routes, the national and the global, the authentic and the anonymous are also felt in other international(ising) institutions. Given the unique nature of the ICRC, a comparison with multilateral agencies  and international NGOs, especially those with headquarters in different regions, would be particularly welcome.


Purpose: Adolescents with cerebral palsy may need a feeding tube due to feeding challenges, since nutritional intake and mealtimes may be negatively affected. The purpose of the study was to describe and better understand how one adolescent with cerebral palsy and her parents experienced mealtimes before and after a nasogastric and gastrostomy tube insertion and how the use of these feeding tubes was experienced in daily life.Methods: Individual interviews were performed with one adolescent and each of her parents. In total, six interviews were conducted on two separate occasions. The qualitative approach known as Interpretive Description was used during the analysis.Results: Four thematic patterns were identified within the data: (i) struggling with nutritional intake, (ii) the paradox of using an aid, (iii) being different, and (iv) challenges of public mealtimes.Conclusions: The results showed that four themes influenced daily mealtimes in adolescents with cerebral palsy and a gastrostomy tube. Nutritional intake and mealtimes may be difficult, which is why using a gastrostomy tube can be a relief. However, the gastrostomy tube can also pose a challenge and a paradox. Time of change and acceptance seems necessary in order to meet these challenges. This case is about an adolescent with cerebral palsy (CP), referred to by the pseudonym Lisa. Deteriorated scoliosis was the origin of her suffering, which, in combination with the scoliosis treatment caused side effects such as behavioural changes regarding nutritional intake and mealtimes. Thus, the goal of pain management was to achieve acceptable pain relief. However, the pain and its side effects could not be adequately relieved. Consequently, Lisa stopped feeding orally and eventually relied on enteral nutrition (EN) via a feeding tube.In CP, inadequate nutritional intake is a serious problem , In adolescents that need EN during a limited period, a nasogastric tube (NG-tube) may be an option, while a gastrostomy tube (G-tube) can be advantageous from a long-term perspective   in December 2017. In January 2018, the NG-tube was changed to a G-tube, and in May 2018, the G-tube was changed to a low profile tube. The EDACS assessment was not performed by the paediatric care team before or after each feeding tube change, since it was clear that Lisa constituted level I of the classification system. Lisa’s need for a feeding tube was not related to any physical obstacles. Therefore, Lisa could receive nutrition and perform mealtimes safely.Purposive sampling was used at a habilitation centre. The inclusion criteria for the study was an adolescent with CP who had experiences of different types of feeding tubes, i.e., an NG- and G-tube. This case study is part of a larger project examining children who, for medical reasons, have received a G-tube. In addition, the children must be five years or older or have a cognitive developmental level of five years or older.The adolescent’s perception was essential, since the adolescent’s own perspective needs to be explained , third (MJN), and last author (SN) have many years’ experience working as paediatric nurses. Additionally, the first (UM) and second author (MC) also have many years’ experience working at a paediatric habilitation centre. The second (MC) and fourth author (KM) have experience in paediatrics, and the fifth author (HW) has experience in caring science.The first author (UM) conducted, recorded, and transcribed all the interviews. Since the purpose of this study was to interpret and describe an adolescent’s everyday life, an Interpretive Description (ID) qualitative approach was adopted, as outlined by Thorne Thorne, . In ID, The analysis consisted of arranging the data and obtaining an overall picture of the case which is essential to the ID process Thorne, . The nexData patterns were grouped into themes. In this way, each participant’s experiences could be described and represented, which in turn resulted in meaningful themes being identified by the first author (UM) and checked by the last author (SN). Finally, four different thematic patterns were identified across the data see , and theTo ensure that descriptive data was interpreted in an appropriate manner by the researchers, the first author (UM) returned to the participants during the analysis process and carried out member checks. This enabled the participants to validate, review and verify the collected data which strengthened the validity of the study . The first author (UM) informed the participants both verbally and in writing about the study and obtained their verbal and written consent to participate. Participation in the study was voluntary, and the participants understood that they could withdraw their participation at any time without providing a reason. Adolescents can be vulnerable, especially adolescents affected by the type of diagnosis included in the study. Therefore, the researchers ensured that they maintained a high degree of respect and consideration throughout the research process. In the study, all information was treated confidentially, no unauthorized persons had access to the data, and steps were taken to ensure that the participants were anonymous. All data was stored in a locked, fireproof filling cabinet.After examining the individual interviews, four thematic patterns were identified from the data: (i) struggling with nutritional intake, (ii) the paradox of using an aid, (iii) being different, and (iv) challenges of public mealtimes. The results provide insight into the mealtime process and Lisa’s experiences over time before and after the tube insertions. In each theme, the results are presented according to Lisa’s experiences, i.e., before and/or after the insertion of the feeding tubes, ending four months after with the low profile tube insertion.Struggling with nutritional intake refers to the period before the NG- or G-tube insertions, where Lisa experienced constant pain and the challenges she faces around mealtimes.Yes, I had probably not realized that it was so bad with the food right then”(Lisa´s father). Both parents described how Lisa, who had eaten orally with a good appetite all her life, progressively began to lack interest in eating: “ … Increasingly more and more morphine was given, which made the appetite disappear” (Lisa´s mother). Bodily discomfort was described as an aspect that may have negatively affected Lisa’s nutritional intake. In this case, serious consequences such as nausea, lack of appetite and weight loss as well as a decline in Lisa’s nutritional intake caused a spiral of negative reactions at mealtimes, and overall deterioration was apparent.Lisa’s parents unanimously asserted that Lisa’s pain and side effects gradually worsened, severely affecting her appetite, although it took time for them to grasp the real seriousness of the situation: “It was very stressful at the beginning to make sure that she would get nourishment, therefore one was completely exhausted … ” (Lisa’s mother). Lisa confirmed that mealtimes during this time were more demanding than enjoyable, which contributed to her feelings of distress: “ … It consumed more energy than I actually managed to take in” (Lisa).Mealtimes, which had normally been a source of joy for the family, had now been replaced with negative emotions such as stress, pressure, and frustration. More specifically, they had become challenging for Lisa since mealtimes were now focused on ensuring that she was obtaining an adequate nutritional intake. Consequently, Lisa’s desire and motivation to eat completely disappeared. The negative atmosphere during mealtimes affected Lisa remarkably. Her feeding problems steadily escalated, which led to difficult mealtimes for both Lisa and her parents: “ … the weight curve went downward … it didn’t work … ” (Lisa). Lisa’s father expressed worry over the situation: “ … she lost a lot of weight, as she had difficulty eating and taking in food through the mouth … ” (Lisa´s father). Insufficient nutritional intake combined with weight loss over time contributed to Lisa’s serious physical situation. Finally, Lisa’s mother felt that, even though her daughter had tried to manage her feeding issues, it was not working anymore. Therefore, she considered a feeding tube as an option for Lisa in order to manage and improve her situation. Lisa’s parents tried to get support from her paediatric care team, asserting Lisa’s need for a feeding tube, since both her health and well-being had been negatively affected. However, they needed to contact the team repeatedly to reiterate the increased need for nutritional support. After a long-term struggle, a decision was made that Lisa needed a feeding tube in order to recover. Lisa was set to have a G-tube but received an NG-tube in the interim.Despite all the attempts made to increase her nutritional intake, including taking dietary supplements, it became clear that Lisa was losing weight: “ … The theme, the paradox of using an aid, came from the period after Lisa had received a G-tube and refers to the tube as being both a solution and an obstacle for the family. In this interpretation, the paradox describes the positives and the ambiguities of living with a G-tube.Lisa thought it was wonderful too I think” (Lisa’s father). The G-tube became a solution to Lisa’s feeding problems, since she no longer dealt with an oral eating requirement. Reduced stress and pressure at mealtimes resulted in less difficulties surrounding Lisa’s nutritional intake. Her parents agreed that the G-tube presented a solution that gave them a sense of control. However, according to Lisa’s parents, the most important advantage of the G-tube was the sense of security it provided. They expressed a sense of relief at having the ability to ensure Lisa’s needs regarding nutrition and medication were met: “ … what a relief … you have at least the opportunity to give [food] even on a difficult day … or to add the medication … There is a sense of freedom to know … ” (Lisa’s mother). The G-tube also gave Lisa a renewed sense of control, giving her a new sense of independence and freedom. Mealtimes improved and became relaxed again: “ … The pressure is not the same … now I have a choice” (Lisa). The change in atmosphere also had a positive impact on the mealtime experience at home. Overall, the G-tube insertion resulted in Lisa’s improved health and well-being, as increased nutritional intake gave Lisa energy, leading to a more active and functional daily life.The whole family viewed the G-tube as a positive change: “ … “ … I feel so nauseous in the morning that I cannot eat the food at home and then I have to eat it at school … ” (Lisa). Furthermore, it was troublesome for Lisa to consume the required amount of food each day and then retain it: “ … we had big problems getting the whole amount to go down, and for it to stay down” (Lisa’s mother).However, despite the G-tube insertion, bodily discomfort—such as nausea and vomiting—remained which proceeded to negatively affect Lisa’s nutritional intake. Due to the nausea, Lisa often felt sick in the mornings making it difficult for her to eat at all. The G-tube had facilitated her food consumption, but because her nausea remained, the bodily discomfort negatively impacted Lisa’s well-being and daily life. It affected her so much that her eating habits needed to be changed: Lisa gets the opportunity to try if she wants. We always ask her if she wants something but … 99 times out of 100 she does not want anything” (Lisa’s father).The G-tube insertion resulted in a continuation of non-oral feeding, which led to frustration for Lisa’s parents. They indicated that the long-term difficulties with food that Lisa faced had been traumatic for her, outlining that she now viewed mealtimes as an obligation and associated food with pressure and stress. Lisa’s parents stated that they often tried to encourage Lisa to eat orally at mealtimes. However, they allowed her to choose her food and the time that she wanted to eat. This was in an attempt to help her feel more involved and motivated at mealtimes. They also tried to promote the meals by presenting the food in an appealing way, since the visual impression of food is important to the mealtime experience, but it did not help. However, Lisa’s parents found that their attempts to make Lisa feel more involved were unsuccessful: “ … “ … We don’t have meals together that often … we all have such different eating habits … ” (Lisa). Therefore, whilst Lisa’s insufficient nutritional intake was solved with the G-tube, new challenges arose, as neither food nor socialization formed a component of Lisa’s mealtimes anymore. Time for change and acceptance was essential for the family to adjust to the new situation after the G-tube insertion.Consequently, Lisa began to skip mealtimes with her family. This came as a relief for Lisa as she experienced this withdrawal as something positive—a quiet moment for recovery on her own. In contrast, her parents saw this as a sign that Lisa was disappearing, isolating herself from them and signified that she was becoming more distant. Therefore, Lisa’s parents tried to physically adapt mealtimes by providing her with another room or space in order to avoid this alienation. Lisa would sit in front of the TV and her meals would be placed there. Consequently, Lisa’s withdrawal resulted in a change in routines and new mealtime habits for the whole family. The physical distance at mealtimes resulted in less social interaction and communication within the family: The theme of being different refers to the family’s different experiences with the two feeding tubes, i.e., the NG- and G-tube.The fact that everyone would look at Lisa in school … ” (Lisa’s father). The change in appearance became hard to manage, and Lisa, with support from her parents, struggled to handle the situation. As an adolescent, Lisa wanted to look like everybody else, and she therefore tried to hide the NG-tube: “Lisa thought it was, it was hard … did not want it to be visible. We struggled to make it as invisible as possible … ” (Lisa’s mother).Lisa had a visible disability all her life, and she was used to receiving reactions and comments about it, which generated a sense of being different. The NG-tube became another visible sign and exacerbated the feeling of being different, causing Lisa to resent negative feelings towards her illness. Physical appearance is important, especially for adolescents, which makes it hard for Lisa to manage the new situation. Her parents described feelings and concerns regarding how strangers would respond to Lisa: “since the button is on the stomach … it may not be ideal … to pull up my sweater in the middle of the hallway” (Lisa). The G-tube also resulted in questions from people outside the family, especially at mealtimes, which Lisa found hard to contend with: “ … I don’t want people to see either … because I don’t want any questions about it” (Lisa).The two feeding tubes given to Lisa—the NG- and G-tube—were experienced very differently by Lisa and her parents. Since the NG-tube became a traumatic experience, it negatively affected Lisa’s well-being. The G-tube insertion thus gave the family a sense of relief since it is an aid that is not visible unlike the NG-tube. However, Lisa still felt different; even though the G-tube was less visible, it still represented that she was different from everyone else, “ … Contrary to Lisa’s father, Lisa’s mother also described a sense of feeling different (as a mother). Specifically, she described how tube feeding affected her emotionally and that at times her role was no longer that of a mother, but instead felt more like that of a worker. However, her experience of feeling different decreased over time, and both Lisa and her mother became used to it. Acceptance and an adaptation was necessary to meet the challenges—e.g., unexpected reactions and feelings—as well as to recover a sense of well-being for the whole family after the G-tube insertion.The theme of challenges of public mealtimes refers to the period before and after the NG- and G-tube insertion. The theme emphasizes how the environment affected Lisa’s mealtimes.“ … It is so boisterous, messy and noisy and people are shouting and there is such little space … I can’t deal with it” (Lisa). Her parents agreed with Lisa that the mealtime environment at school required a lot of Lisa’s strength and energy in order to handle it: “ … she does not want to go into the school cafeteria at all … it is messy … and loud and there are many people … it is a stressful situation … ” (Lisa’s mother). The cafeteria and its atmosphere were aspects that negatively influenced Lisa’s mealtime experiences.According to Lisa, public mealtimes were a struggle which resulted in her avoiding places like restaurants, major events and the school cafeteria, i.e., places with many people. The most common public mealtime that had a major effect on Lisa’s daily life was the school cafeteria. The prevailing school mealtime environment, which featured significant amounts of noise, resulted in Lisa having severe difficulties in coping with her mealtimes in the cafeteria: Before Lisa received enteral nutrition, she was required to eat at the school cafeteria. When the G-tube insertion was administered, new possibilities arose, including withdrawal from the cafeteria, presenting a solution and new ways for Lisa to cope. The G-tube had made it possible for Lisa to both ensure her nutritional intake at school and, at the same time, avoid an uncomfortable environment. Withdrawal from the school cafeteria was a solution Lisa chose; she saw it as a beneficial option to eat with more privacy, which in turn enhanced her ability to recover and improved her overall well-being at school.“ … I think the assistant is asking Lisa but she gives her a definitive ‘no’ each time … ” (Lisa´s father). Thus, time of change and acceptance also appeared to be an important aspect for those outside the family with whom Lisa came into contact with.Instead of using all her time and energy to focus on eating in the cafeteria, Lisa now had the energy to socialize and interact with her schoolmates during breaks. Despite Lisa’s own choice not to participate in mealtimes at school, she was regularly encouraged to join her schoolmates to eat in the cafeteria. The school staff did not appear to feel comfortable with Lisa’s choice: This unique case study emphasizes the adolescent’s experience and perspective of mealtimes in conjunction with the use of feeding tubes—an NG- or G-tube—which are valuable and of great importance for paediatric care. Using the M-FAMM  associated symptoms (Kakade et al., A G-tube even though may be challenging for an adolescent with CP, it could lead to improvements in physical health (Mahant et al., The family in this study experienced a sense of relief when the G-tube was finally inserted, since it resulted in less pressure at mealtimes, which is in line with earlier research (Backman et al., The feeling of being different was intensified for the adolescent in this study after the NG-tube insertion. This feeling remained despite the change to the G-tube. Lisa’s external appearance became different, contributing to a sense of being more conspicuous than before. It has previously been highlighted that a feeding tube can be perceived as an obvious sign of an adolescent’s difficulties, garnering potentially problematic reactions from other people (Nelson et al., The transition from an NG-tube to a G-tube can be a positive experience for an adolescent with CP, contributing to beneficial changes in health, well-being, and external appearance (Quitadamo et al., In this study, Lisa avoided public mealtimes such as the school cafeteria. Therefore, the environment and atmosphere are aspects that need to be taken into consideration in order to get a holistic view of the mealtimes (Mårtensson et al., A limitation of this study is the methodological criticism that is frequently aimed at case studies in general. This includes, for example, criticism of the lack of relevance of a single case due to poor generalizability. However, the purpose of this study is not to create generalizable knowledge but to lead to an in-depth understanding of the studied phenomenon. The findings can help in understanding adolescents’ experiences regarding mealtimes in daily life before and after an NG- or G-tube insertion. Another limitation of this case study is that all of its data came from the family, with only one adolescent with CP and her parents interviewed. No one outside the family, such as health care professionals, assistants or school staff, was interviewed. It is clear that the opinions of one single adolescent cannot accurately reflect those held by every individual with CP, as each individual has his or her own unique lived experience, which affects the generalizability of case studies in general. However, such studies do reveal aspects of individuals’ everyday lives, thereby providing guidance regarding how, for example, mealtime experiences might be perceived when an adolescent with CP lives with an NG- or G-tube. Further, the use of the M-FAMM (Mårtensson et al., This unique case study provides a further understanding of mealtimes before and after the insertion of an NG- or G-tube. The results give valuable insight regarding a specific adolescent’s lived experience, which can contribute to a deeper understanding of the area. The findings of the study indicate that insufficient nutritional intake combined with weight loss over time may lead to severe physical conditions for an adolescent with CP. As a result, the paediatric care team needs to be aware of the effect of bodily discomfort in these adolescents, particularly on nutritional intake and mealtime experiences.By using this in-depth knowledge, nursing students as well as paediatric care teams may receive specific information and education regarding the challenges adolescents with CP may experience regarding mealtimes and feeding tubes. This knowledge may contribute to being better prepared to care for adolescents. The knowledge could also be used to educate parents about the challenges an adolescent can experience regarding mealtimes and the use of feeding tubes. By using the M-FAMM (Mårtensson et al., Further studies involving a larger number of adolescents are needed to get a broader perspective of mealtime experiences with a feeding tube. In addition, it is important to underscore the difference between the mealtime experiences of children with CP in different age groups as well as those of children/adolescents with a long-term use of feeding tubes. This in order to identify similarities and differences in their experiences in order to customize the care and treatment to the specific child/adolescent. It is also important to further investigate how innovations can be developed, e.g., new guidelines and a platform of education, with the purpose of optimizing care, treatment and support for these adolescents.This study, which is done from an adolescent’s perspective, emphasizes the adolescent’s own experience of using a feeding tube and its impact on daily mealtimes before and after the insertion. The results showed that four themes influenced the adolescent’s daily life: struggling with nutritional intake, the paradox of using an aid, being different, and challenges of public mealtimes. Nutritional intake and mealtimes may be difficult for an adolescent with CP, and a G-tube can be a solution. However, the G-tube can also pose a challenge and a paradox, why time of change and acceptance seems to be necessary in order to meet challenges that may occur.


To remain competitive with other professions, job satisfaction is a critical issue; however, to date, there are no data available on the German EMS. This study aims to perform a statistical analysis of job satisfaction and performance orientation and to identify risk factors for low job satisfaction of paramedics in the German EMS. (2) Methods: Data were collected from 2590 paramedics through a nationwide cross-sectional survey, using the job satisfaction questionnaire by Neuberger and Allerbeck and the performance orientation questionnaire by Hippler and Krüger. Descriptive and regression statistical analysis were performed. (3) Results: The participants scored significantly lower than the reference sample on job satisfaction, with “organization and management” and “payment” being the lowest rated subscales. Around 9% of employees feared losing their jobs. While work attitude toward performance and success enhancement was high, fear of failure was also common. (4) Conclusions: Job satisfaction of paramedics in the German EMS is below that of the reference sample. Discontent with payment and organizational issues is common. Performance orientation is high, but fear of failure is frequent. Current and future efforts that aim at an attractive working environment should reflect on these findings. Rising numbers of emergency medical service (EMS) missions and a developing shortage of skilled health care workers are global issues . The necEven before the COVID-19 pandemic, the number of emergency and non-emergency missions together increased by nearly 50% between 1994 and 2013 in the German EMS .Among paramedics in the US, the annual turnover in employees is almost 10% ,8. In IsTurnover of employees is not only associated with high workload for employers and torn personal relationships but also with high costs and the loss of knowledge and experience. Retention of new well-trained employees in the EMS is difficult and highly competitive among the agencies .Low job satisfaction can be problematic both in terms of shortage of skilled workers and the health of each employee. In a study by van der Ploeg et al., factors such as lack of social support from colleagues and supervisors as well as poor communication were found to be significant predictors of posttraumatic stress disorder, burnout symptoms, and fatigue . These sBeside the external factors—such as the swelling number of emergency missions and a growing share of elderly people in the population—internal stressors, such as structural changes in the EMS system itself, with rising responsibility for the paramedics and increasing cost pressure for the EMS system in general, are putting the EMS system in Germany under steadily growing pressure.In 2017, the German EMS employed approximately 62,000 people, of whom, 24% were women [In the last few years, a significant change has taken place in the German EMS. It has been restructured, and the new profession of “Notfallsanitäter” has been introduced. At this moment there are three categories of paramedics. The path to the new profession of “Notfallsanitäter” comprises a three year vocational training. “Notfallsanitäter” are legally allowed to perform certain tasks at their own discretion that were previously performed by physicians only, and they usually act as the team leader of an emergency ambulance crew. The previous profession of “Rettungsassistent,” which required a two year training period, can still be considered as the team leader of an ambulance crew, but in a few years, all “Rettungsassistent” will be required to complete additional training if they want to remain in this position. The third category of “Rettungssanitäter” requires only 13 weeks of training and involves subordinate duties and responsibilities.This structural change means an increase in responsibility for paramedics, who will now make decisions about how to treat patients without the backup of an emergency physician. At present, it is unclear how this change will affect the meta-levels of paramedics’ work. There are no data available addressing issues such as performance orientation, career orientation, performance-enhancing work attitudes, or fear of failure. In our opinion, the high level of quality of medical procedures, as currently performed by physicians, must be maintained—without overwhelming paramedics with their new responsibilities. To date, there is also no detailed information available that could help in the analysis of the different aspects of job satisfaction and in the possible explanations for the high rate of dissatisfaction among employees in the German EMS. This study aims to perform a statistical analysis of job satisfaction and performance orientation and to identify risk factors for low job satisfaction of paramedics in the German EMS.In autumn 2017, a nationwide, German, cross-sectional questionnaire survey was conducted to collect sociodemographic data on ambulance workers and to identify indicators of job satisfaction and performance orientation. The study was widely advertised through information letters, posters, and flyers that were sent to all German EMS stations and paramedic academies. Announcements were printed in all major German EMS journals. Relief organizations, labor unions, and the German Association of Paramedics (Bundesverband Rettungsdienst) have supported our study through their online communications.The survey was conducted as an online questionnaire provided via the SoSci-Survey platform. Participation was voluntary and anonymous.Questionnaires with more than 20% missing answers were excluded from the analysis. The emergency physicians were not included in the survey because of their different working conditions.The University of Erlangen-Nuremberg’s research ethics committee approved of our study by formal decision (Decision Number 172-17B). The need for formal consent from the participants was waived by the ethics committee, and voluntary participation served as a surrogate for consent.To collect the participants’ sociodemographic data, questions about age, gender, height, and weight were included. Height and weight were recorded, because work in the EMS is often associated with physical strain. Information about professional experience was also collected, including the highest level of professional training, number of years spent working in EMS, and an estimate of the total number of emergency missions handled to date.Questionnaires developed by previous studies were used to identify indicators for job satisfaction and performance orientation: the job satisfaction questionnaire by Neuberger and Allerbeck  and the The job satisfaction questionnaire by Neuberger and Allerbeck consists of 7 subscales. Each subscale contains several questions to investigate on every aspect of the subscale. In total, 79 items are included. Every item is rated on a scale from 1 = “yes” to 4 = “no.” Since “yes” is positive for some items and negative for others, some items have to be reversed. The mean of the added values indicates the level of satisfaction from 1 = low satisfaction to 4 = high satisfaction. Since questions of the different subscales vary in their complexity of subjective assessment, a cumulative question at the end of each subscale “All in all, how satisfied are you with…”—was asked to allow direct comparison of subscales. This question was presented using Kunin faces, ranging from 1 = very dissatisfied (face with a downturned mouth) to 7 = very satisfied (laughing face). Other collective questions, such as “All in all, how satisfied are you with your job?” and “All in all, how satisfied are you with your life?”, were also rated on a 7 item Kunin face scale.Additionally, the questionnaire addresses the arrangement of working hours and asks about fear of job loss. The participants were able to indicate the degree of their approval to the questions “The danger of losing my job is high” and “I am satisfied with the arrangement of my working hours” with “yes,” “rather yes,” “rather no,” and “no.”To relate job satisfaction of EMS employees with other professions, the current data was compared to a standard reference sample, provided by Neuberger, which has been made up of more than 2000 employees of various professions [The performance orientation questionnaire by Hippler and Krüger consists of 26 items organized into three subscales: “career orientation,” “performance- and success-enhancing work attitude,” and “fear of failure.” Each item can be rated from 1  to 7 (“I completely agree”). At the end, the mean of all items is calculated. The career orientation subscale mainly includes aspects of future orientation, resilience, assertiveness, social competition, and level of ambition. The performance- and success-enhancing work attitude subscale primarily consists of aspects of persistence, professional task completion, and assertiveness. The last subscale, fear of failure, consists of negative feelings, such as fear of embarrassment, worry about important events, and preference for tasks with a foreseeable end.p < 0.05. Values are presented as means with standard deviations and medians with interquartile ranges, where appropriate.The data we gathered is available via a persistent digital object identifier (DOI), linking to the dataset stored in the Zenodo data repository. Statistical analysis was performed using SPSS Statistics 24.0.0.0 , and statistical significance was defined as We used descriptive statistical analysis to describe the underlying study population in terms of age, gender distribution, BMI, level of training, and work experience.t-test was used. The Wilcoxon test was used to compare items in the questionnaire that used rating scales.The aim of this study was to investigate the job satisfaction of paramedics in German EMS. In a first step, the results were put in comparison to a general representative sample of German employees. In order to elucidate the differences of the representative sample and the mean values of the paramedics group, a one-sample Since there are significant differences between the representative sample and the paramedics group, we investigated the results of the paramedics group more closely in a second step. To identify causes of low job satisfaction, we divided the paramedics in two groups. Group 1, with low job satisfaction, who chose a Kunin face with a downturned mouth (1–3), were compared with those with high job satisfaction, who chose a Kunin face with an upturned mouth (5–7). Afterwards, a binary regression analysis with a stepwise selection of predictor variables was carried out. Job satisfaction was thereby used as the dependent variable, whereas the paramedics’ personal characteristics were used as independent variables.A total of 2731 employees completed the questionnaire. Due to the described mode of questionnaire dissemination, a distinct response rate could not be calculated.In sum, data from 2590 paramedics could be analyzed. The sample size for an analyzed items may vary from the total sample size, due to incomplete answers.In the first step of our analysis, the group of paramedics were put in comparison to the representative sample to investigate the difference of EMS employees from the general population. In this comparison, statistically significant differences were found for all subscales of job satisfaction between the cohort of paramedics and the representative sample provided by Neuberger , which sEach subscale was rated lower by the paramedics. The categories of “organization and management” and “my payment” showed the biggest differences when compared with the reference group’s responses; whereas the categories of “my development” and “my activity” showed the smallest differences. The two worst-rated categories, “organization and management” and “payment,” were examined more closely at the single item level. For the category “organization and management,” the participants indicated that higher management was cumbersome, were uninterested in the opinions of paramedics, and only provided insufficient organizational information, and that employees were not proud of their organization . For theIn a second step, every subscale was rated in a summarizing question—“All in all, how satisfied are you with …”—was rated on a scale of 7 Kunin faces, ranging from 1 (lowest satisfaction) to 7 (highest satisfaction).The data shows that the subscales “my activity” and “my colleagues” were rated the highest. Again, the worst-rated categories were “organization and management” and “payment.” p = 0.59).In terms of the summary question—“All in all, how satisfied are you overall with your job?”—16.5% of the participants chose a negative Kunin face (downturned angle of mouth), and 65% picked a positive Kunin face (upturned angle of mouth). For the question “All in all, how satisfied are you overall with your life?”, 20.4% selected a negative Kunin face, and 63.4% chose a positive Kunin face. Job and life satisfaction showed no significant difference using Wilcoxon’s test  were compared to those who chose a Kunin face with an upturned mouth (5–7). By this analysis, we were able to identify factors that were associated with higher job satisfaction, as follows:p < 0.01); ages between 18 and 30 years , and between 31 and 40 years ; being “Notfallsanitäter in training”  resulted in a higher probability of reporting high job satisfaction; being qualified as “Rettungsassistent” resulted in a probability of reporting low job satisfaction   . The othp < 0.01). Nagelkerke’s R2-value was 0.075. The complete model was significant (chi-squared (12) = 102.10, The questionnaire by Hippler and Krueger was used to elicit data on performance orientation. Each subscale has a possible value from 1 (low) to 7 (high) points.The paramedics reported a mean career orientation value of 4.34 points. Only a few paramedics had a very strong or a very weak career orientation.Compared with career orientation, performance- and success-enhancing work attitudes showed higher values. The mean was 5.53, and most of the paramedics had a high interest in carrying out the tasks assigned to them professionally.The mean for the subscale “fear of failure” was 4.55. For this item, higher scores indicate a greater fear of failure.The shortage of skilled workers is a relevant problem in German health care, and it is predicted to worsen in the coming years. For a health discipline to remain competitive in comparison to other occupations, job satisfaction is a critical factor. To date, there is no nationwide data on job satisfaction in paramedics. In our study, we included a dataset with more than 2500 employees, and found that low job satisfaction is a pertinent issue in the German EMS.The question “All in all, how satisfied are you with your job?” was answered with a negative Kunin face by 16.5% of participants. This was a lower rate of dissatisfaction among paramedics than was shown by Baier et al., but it still indicates a need to be concerned, given the forecast of skilled worker shortages . To remaOn a positive note, core EMS tasks themselves achieved the highest ratings compared with all other areas of job satisfaction. There was no significant difference to the representative sample. Furthermore, the worst-rated areas are amenable, in principle, to change and improvement.In numerous previous studies personal relations to coworkers played a key role in job satisfaction among EMS paramedics ,21,22. SAspects of “organization and management” and “salary” scored lowest in our study population. The discontent with the salary agrees with previous results from studies among American ,23 and IIn the category “organization and management,” three out of the six worst-scoring questions were related to management–employee communication. The participants’ responses indicate that employees think they do not receive sufficient information, and that management is not interested in their opinions. These areas might be a starting point for improving employee satisfaction. Interestingly, these findings have not been reported in previous, international studies ,22,23.The difficulties in management–employee communication could arise due to the situation in Germany, in which several independent relief organizations are responsible for the emergency services across the country. It might be challenging to get all employees to the same level of knowledge when there are several different organizations in one city.Regular informational letters and the opportunity for employees to submit suggestions for improvement to the management could be easy ways to improve job satisfaction. The EMS management could look for suggestions in other occupational fields, in which comprehensive job satisfaction strategies have been successfully implemented.Interestingly, the participants’ direct supervisors received much better ratings than the superimposed levels of organization and management. The reasons for this finding remain unclear, but it is possible that direct supervisors have a better understanding of their employees’ needs, because they are mostly paramedics themselves, while higher-level management consists of physicians, politicians, and economists.The worst category of job satisfaction was the participants’ pay. An analysis of individual questions related to payment indicated that the paramedics did not think their salary corresponded to their responsibilities. These findings go along with results from American paramedics, who were least satisfied with payment and the possibilities of advancement . Dopelt This finding becomes even more worrisome, given that in the future, additional medical measures will be performed by paramedics rather than by physicians. Decision-makers should carefully weigh whether this extension of responsibilities should be compensated for in monetary terms.The item “The danger of losing my job is high” was answered as “no” or “not very much” by more than 90% of the participants. This finding, which appears positive at first glance, might also be indicative that employers would avoid losing employees at all costs because of an impending shortage of skilled workers.Another aspect of improving job satisfaction could be a more flexible scheduling of work shifts, as only 23.2% of the participants answered the question “I am satisfied with the arrangement of my working hours” with “yes”, while 17.6% answered with “no”. The reasons for this wide range of satisfaction levels remain unclear, but if further research indicates that it could depend on different duty rosters and not on personal factors, then there could be a potential for optimization.In a binary regression analysis, we were able to identify some risk factors for low job satisfaction. Although these factors were mathematically significant, we will not discuss them further because Nagelkerke’s R2-value was only 0.075, which indicates a poor model fit. Other influencing factors on job satisfaction must be present that were not part of our questionnaire. It is possible that family and social background play an important role. Further investigations into these and other causes of low job satisfaction are needed at this point.Finally, we found a strong performance- and success-enhancing work attitude in paramedics. This indicates that most paramedics want to adequately perform the tasks assigned to them professionally. One of the reasons for low-skilled paramedics to consider leaving the EMS is the motivation for further education . EspeciaIn particular, sound training and regular evaluations of both performance levels and paramedics’ feelings could play an important role. Hopefully, a sustainable working environment can be created in this way.Additionally, since all medical professions alike are threatened by a shortage of skilled labor, we recommend performing more studies of this kind on other medical professions.Naturally, our findings come with limitations. Despite the study’s extensive distribution across the entire German EMS, a relevant selection bias of participants cannot be ruled out. It remains uncertain what motivated paramedics to participate in this study, and whether the willingness to participate is correlated with the variables investigated in this study.Secondly, in this study, the subjective ratings gathered from employees were not paired with corresponding assessments from the employers. It is conceivable that views on various items might be different depending on the perspective people may have regarding the employment contract.Moreover, it will be difficult to compare the current findings with data from other countries, as divergent cultural and economic backgrounds may have a major impact on employees’ ratings of their job and on the effort they are putting in.An assessment of the German paramedics’ jobs reveals that they are most satisfied with the nature of their work and with their immediate colleagues. They have little fear of losing their employment. However, they are least satisfied with their organization’s management and their pay. Efforts to improve job satisfaction could work on both top-to-bottom and bottom-to-top communication patterns as “low-hanging fruits” of success. The high-performance orientation of paramedics is reassuring, considering the vital responsibilities of their profession. However, future extensions of their duties should reflect on the fear of failure as a common trait in their cohort. Finally, interventions and future developments in the EMS profession should be evaluated with regard to their effect on job satisfaction and performance orientation, by repeating our assessment at regular intervals.