Causes of stress and poor wellbeing among paramedic students in Saudi Arabia and the United Kingdom: a cross-cultural qualitative study

**Background:** Paramedicine students face numerous challenges that threaten their wellbeing, with studies showing higher rates of anxiety (24%), depression (28%), and PTSD (16.8–20.2%) compared to the general population. Despite this, few studies have examined factors contributing to stress in paramedic students, and none have included cross-cultural comparisons. This study aimed to explore paramedicine students' training experiences and education-related factors affecting wellbeing, and to identify differences and similarities between Saudi Arabia and the UK.

**Methods:** A qualitative exploratory research design was used. Twenty semi-structured interviews were conducted (10 from SA, 10 from UK) between April and June 2022 via remote video platform. SA participants were 7 male and 3 female, aged 19–25, all Saudi nationals and single, enrolled in 4-year undergraduate programmes plus 1-year internship (years 3–5). UK participants were 3 male and 7 female, aged 19 to >31, all White British, with 7 single, 2 married, 1 divorced, enrolled in 3-year undergraduate programmes (years 1–3). Reflexive thematic analysis following Braun and Clarke's six steps was employed. The lead author (AA) conducted all interviews; 10% of transcripts were double-checked by CK and JJ. Data saturation was reached at SA=8 and UK=7 participants.

**Key Results:** Four major themes were identified: 1. **Exposure to potentially traumatic events** – Participants from both cultures reported traumatic events related to patient care (e.g., death, paediatric patients, communicable disease patients). Training environments were a significant stressor, including unsafe conditions, verbal or physical assault, and misogynistic sentiment. Early clinical placements (as early as 6 weeks into UK programmes) increased vulnerability. Shift work disrupted sleep and self-care. 2. **Relationships and communication** – Faculty members could positively or negatively impact wellbeing through support or neglect. Peer and family support was essential, but participants carefully moderated information shared with family. Training proctors played a crucial role; when proctors adopted roles as friend and mentor, stress was reduced, but unwelcoming proctors caused significant distress. Some participants witnessed errors or misconduct but felt unable to intervene. 3. **Programme atmosphere** – Participants reported stress from preparatory years (SA), exclusive focus on scientific subject matter, and lack of practical mental health teaching. Support varied: some felt isolated and unsupported, while others benefited from tripartite reviews and wellbeing emails. SA participants highlighted extracurricular activities as important; UK participants did not. 4. **Career** – SA participants showed less awareness of the paramedicine specialty and more concern about limited job availability. UK participants were more aware of the specialty but expressed anxiety about stressors. Female SA participants had added anxieties related to societal gender expectations; female UK participants reported concerns about male-dominated specialties.

**Clinical Implications:** The study reveals that stressors are similar across both cultures, suggesting universal challenges in paramedicine training. Universities should provide students with greater access to information about paramedicine before enrolment, create open and supportive learning environments, and implement inclusive social activities. Training programmes should carefully vet and incentivize proctors, establish clear communication channels, and provide on-site and university-based mental health support. Early clinical placements should be accompanied by adequate preparation. The findings should help educators and policymakers identify and deliver interventions to support paramedic student wellbeing.