The LEAD (Leadership Experiences And Direction) study: exploring top-down cultures, everyday ethics and mutual influence in UK paramedics' experiences of senior leadership

Aim: This exploratory qualitative study examined the experiences of frontline ambulance staff in English NHS ambulance services regarding their senior leadership. Background: Recently, leadership effectiveness in English ambulance services has attracted significant regulatory and policy attention following failures in organisational culture, staff wellbeing and patient safety. Despite strategic initiatives to enhance leadership development, government regulatory inspections continue to identify dysfunctional leadership practices, including a possible disconnect between leaders and frontline operations, insufficient staff support, and ambivalence towards toxic workplace cultures. Limited research has explored how English ambulance staff directly experience and perceive their senior leaders. This study seeks to fill this gap. Method: An exploratory-descriptive qualitative methodology employing semi-structured interviews was utilised. Participants were purposively recruited via social media. Ten frontline ambulance staff, all in operational roles in England, participated in recorded online interviews. Transcribed data was analysed using Reflexive Thematic Analysis, within an interpretivist-constructivist paradigm. Results: Analysis revealed three major themes: (a) Culture - encompassing communication effectiveness, organisational transparency, and psychological safety; (b) Ethics - including honesty, accountability, fairness in decision-making, and compassion; and (c) Influence - examining external pressures, professional voice, clinical understanding, and impacts upon retention. Participants reported having valued leaders who demonstrated authentic communication and genuine connection, while describing how poor visibility, ambiguous messaging, and perceived dishonesty had often fostered dysfunctional coping strategies within the workforce. Participants particularly attributed disconnection between strategic and operational levels to high turnover in leadership personnel, who were often seen to be politically rather than practically ambitious, and a lack of direct clinical experience among senior leaders. Conclusion: Although participants recognised external constraints on senior leaders, and cited many examples of good practice, their reported experiences routinely highlighted significant gaps between leadership strategies and operational realities that contributed to staff attrition which was perceived to contribute to a compromised organisational performance.