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This abstract describes a mixed methods program of research undertaken in a single paramedic service in Ontario, Canada, following the introduction of a novel, point-of-event violence reporting process. Broadly, the research seeks to describe (1) the prevalence and characteristics of violence against paramedics; (2) its contributing circumstances; and (3) risk factors for development.

Purpose Violence against paramedics is a complex – but underreported – problem. Extant research suggests organizational culture may play a role in sustaining cultural norms that downplay the significance and limit reporting. The purpose of this paper is to qualitatively explore paramedics’ experience with violence, with particular emphasis on understanding how organizational culture contributes to under-reporting. Design/methodology/approach The authors surveyed paramedics from a single, large, urban service in Ontario, Canada, asking participants to describe their experiences with violence, including whether – and why or why not – the incidents were reported. Within a constructivist epistemology, we used inductive thematic analysis with successive rounds of coding to identify and then define features of organizational culture that limit reporting. Findings A total of 196 (33% of eligible) paramedics completed the survey. Fully 98% of participants disclosed having experienced some form of violence; however, only a minority (40%) reported the incidents to management, or the police (21%). The authors defined a framework within which a lack of support from management, and consequences for offenders, implicitly positions the ability of paramedics to “brush off” violent encounters as an expected professional competency. Disclosing emotional or psychological distress in response to violent encounters invited questions as to whether the individual is personally suited to paramedic work. Originality/value While the extant research has indicated that underreporting is a problem, the findings shed light on why – a critical first step in addressing what has been described as a serious public health problem.

Role identity theory describes the beneficial effects on health as a result of the purpose and meaning from occupying social roles. Amid high rates of mental illness among paramedics, we surveyed 5...

Introduction: Like other public safety professions, paramedicine has historically been a male-dominated occupation, both in the demography of its workforce and in its organizational culture. Although women are increasingly choosing paramedicine as a career, participation in leadership roles remains limited. Drawing on data from a recent comprehensive mental health survey, we describe the proportion of women in leadership in a single, large, urban paramedic service in Ontario, Canada. Methods: We distributed an in-person, paper-based survey during the fall 2019 - winter 2020 Continuing Medical Education (CME) sessions. Participating paramedics completed a demographic questionnaire alongside a battery of mental health screening tools. We assessed the demography of the workforce and explored differences in employment classification, provider level (e.g., primary vs. advanced care), and participation in formal leadership roles along self-reported gender lines. Results: Out of 607 paramedics attending CME, we received 600 completed surveys, with 11 excluded for missing data, leaving 589 for analysis and a 97% response rate. Women comprised 40% of the active-duty paramedic workforce, with an average of 8 years of experience. Compared to men, women were more than twice as likely to have a university degree (Odds Ratio [OR] 2.02), but almost half as likely to practice at the Advanced Care Paramedic level (OR 0.61), and somewhat less likely to be employed full-time (OR 0.77). Women were nearly 70% less likely to hold a leadership role in the service compared to men (OR 0.36), occupying just 20% of leadership positions. Conclusion: Although paramedicine is witnessing an encouraging shift in the demography of its workforce with greater participation from women, there is still work to be done, particularly in leadership. Future research should focus on identifying and ameliorating barriers to career advancement among women and other historically underrepresented people.

People find purpose and meaning from having social roles, which, in turn, is important for health and well-being. Paramedics hold a respected role, but also have high rates of mental illness. I interviewed paramedics to understand how paramedic identity develops and what happens when it is threatened due to disability.

BackgroundViolence against paramedics has been described as a “serious public health problem” with the potential for significant physical and psychological harm, but the organizational culture within the profession encourages paramedics to consider violence as just ‘part of the job’. The result is that most incidents of violence are never formally documented. This limits the ability of researchers and policymakers alike to develop strategies that mitigate the risk and enhance paramedic safety. ObjectivesFollowing the development and implementation of a novel, point-of-event violence reporting process in February 2021, our objectives are to: (1)Estimate the prevalence of violence and generate a descriptive profile for incidents of reported violence (2)Identify potentially high-risk service calls based on characteristics of calls that are generally known to the responding paramedics at the point of dispatch (3)Explore underpinning themes, including intolerance based on gender, race, and sexual orientation, that contribute to incidents of violence; and finally (4)Explore the potential contribution of frequent callers on the risk of violenceMethodsOur work is situated in a single paramedic service in Ontario, Canada. Using a convergent parallel mixed methods approach, we will retrospectively review one year of quantitative and qualitative data gathered from the External Violence Incident Reporting (EVIR) system. The EVIR is point-of-event reporting mechanism embedded in the electronic Patient Care Record (ePCR) developed through an extensive stakeholder engagement process. When completing an ePCR, paramedics are prompted to file an EVIR if they experienced violence on the call. Our methods include using descriptive statistics to estimate the prevalence of violence and describe the characteristics of reported incidents (Objective 1); logistic regression modelling to identify high-risk service calls (Objective 2) and the potential contribution of frequent callers on the risk of violence (Objective 4); and finally, qualitative content analysis of incident report narratives to identify underpinning themes that contribute to violence (Objective 3). ResultsWe anticipate being able to provide much needed epidemiological data on the prevalence of violence against paramedics in a single paramedic service, its contributing themes, and potential risk factors. ConclusionsOur findings will contribute to a growing body of literature demonstrating that violence against paramedics is a complex problem whose solutions require a nuanced understanding of its scope, risk factors, and contributing circumstances. Collectively, our research will inform larger, multi-site prospective studies already in the planning stage and inform organizational strategies to mitigate the risk of harm from violence.

BACKGROUND Violence against paramedics has been described as a serious public health problem with the potential for significant physical and psychological harm, but the organizational culture within the profession encourages paramedics to consider violence as just “part of the job.” Therefore, most incidents of violence are never formally documented. This limits the ability of researchers and policy makers to develop strategies that mitigate the risk and enhance paramedic safety. OBJECTIVE Following the development and implementation of a novel, point-of-event violence reporting process in February 2021, our objectives are to (1) estimate the prevalence of violence and generate a descriptive profile for incidents of reported violence; (2) identify potentially high-risk service calls based on characteristics of calls that are generally known to the responding paramedics at the point of dispatch; and (3) explore underpinning themes, including intolerance based on gender, race, and sexual orientation, that contribute to incidents of violence. METHODS Our work is situated in a single paramedic service in Ontario, Canada. Using a convergent parallel mixed methods approach, we will retrospectively review 2 years of quantitative and qualitative data gathered from the External Violence Incident Report (EVIR) system from February 1 2021 through February 28, 2023. The EVIR is a point-of-event reporting mechanism embedded in the electronic patient care record (ePCR) developed through an extensive stakeholder engagement process. When completing an ePCR, paramedics are prompted to file an EVIR if they experienced violence on the call. Our methods include using descriptive statistics to estimate the prevalence of violence and describe the characteristics of reported incidents (Objective 1), logistic regression modeling to identify high-risk service calls (Objective 2), and qualitative content analysis of incident report narratives to identify underpinning themes that contribute to violence (Objective 3). RESULTS As of January 1, 2023, 377 paramedics—approximately 1 in 5 active-duty paramedics in the service—have filed a total of 975 violence reports. Early analysis suggests 40% of reports involved a physical assault on the reporting paramedic. Our team is continuing to collect data with more fulsome analyses beginning in March 2023. Our findings will provide much-needed epidemiological data on the prevalence of violence against paramedics in a single paramedic service, its contributing themes, and potential risk factors. CONCLUSIONS Our findings will contribute to a growing body of literature demonstrating that violence against paramedics is a complex problem that requires a nuanced understanding of its scope, risk factors, and contributing circumstances. Collectively, our research will inform larger, multisite prospective studies already in the planning stage and inform organizational strategies to mitigate the risk of harm from violence. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/37636

There is growing recognition in research and policy of a mental health crisis among Canada’s paramedics; however, despite this, epidemiological surveillance of the problem is in its infancy. Just weeks before the emergence of the COVID-19 pandemic, we surveyed paramedics from a single, large, urban paramedic service in Ontario, Canada to assess for symptom clusters consistent with post-traumatic stress disorder (PTSD), major depressive disorder, and generalized anxiety disorder and to identify potential risk factors for each. In total, we received 589 completed surveys (97% completion rate) and found that 11% screened positive for PTSD, 15% screened positive for major depressive disorder, and 15% screened positive for generalized anxiety disorder, with one in four active-duty paramedics screening positive for any of the three as recently as February 2020. In adjusted analyses, the risk of a positive screen varied as a function of employment classification, gender, self-reported resilience, and previous experience as a member of the service’s peer support team. Our findings support the position that paramedics screen positive for mental disorders at high rates—a problem likely to have worsened since the onset of the COVID-19 pandemic. We echo the calls of researchers and policymakers for urgent action to support paramedic mental health in Canada.

There is growing recognition in research and policy of a mental health crisis among Canada’s paramedics but despite this, epidemiological surveillance of the problem is in its infancy. Just weeks before the emergence of the COVID-19 pandemic, we surveyed paramedics from a single, large, urban paramedic service in Ontario, Canada to assess for symptom clusters consistent with Post-Traumatic Stress Disorder (PTSD), major depressive disorder, and generalized anxiety disorder and to identify potential risk factors for each. In total, we received 589 completed surveys (a 97% completion rate) and found that 11% screened positive for PTSD, 15% for depression, and 15% for anxiety, with 1 in 4 active-duty paramedics screening positive for any of the three as recently as February 2020. In adjusted analyses, the risk of a positive screen varied as a function of employment classification, gender, self-reported resilience, and previous experience as a member of the service’s peer support team. Our findings support the position that paramedics screen positive for mental disorders at high rates – a problem likely to have worsened since the onset of the COVID-19 pandemic. We echo the calls of researchers and policymakers for urgent action to support paramedic mental health in Canada.

Role identity theory describes the purpose and meaning in life that comes, in part, from occupying social roles. While robustly linked to health and well-being, this may become, however, when an individual is unable to fulfil the perceived requirements of an especially salient role in the way that they believe they should. Amid high rates of mental illness among public safety personnel, we interviewed a purposely selected sample of 21 paramedics from a single service in Ontario, Canada to explore incongruence between an espoused and able-to-enact paramedic role identity. Situated in an interpretivist epistemology, and using successive rounds of thematic analysis, we developed a framework for role identity dissonance wherein chronic, identity-relevant disruptive events cause emotional and psychological distress. While some participants were able to recalibrate their sense of self and understanding of the role, for others, this dissonance was irreconcilable, contributing to disability and lost time from work. In addition to contributing a novel perspective on paramedic mental health and well-being, our work also offers a modest contribution to the theory in using the paramedic context as an example to consider identity disruption through chronic workplace stress.

Patients with COVID-19 who require aerosol-generating medical procedures (such as endotracheal intubation) are challenging for paramedic services. Although potentially lifesaving for patients, aerosolizing procedures carry an increased risk of infection for paramedics, owing to the resource limitations and complexities of the pre-hospital setting. In this paper, we describe the development, implementation, and evaluation of a novel pre-hospital COVID-19 High-Risk Response Team (HRRT) in Peel Region in Ontario, Canada. The mandate of the HRRT was to attend calls for patients likely to require aerosolizing procedures, with the twofold goal of mitigating against COVID-19 infections in the service while continuing to provide skilled resuscitative care to patients. Modelled after in-hospital ‘protected code blue’ teams, operationalizing the HRRT required several significant changes to standard paramedic practice, including the use of a three-person crew configuration, dedicated safety officer, call–response checklists, multiple redundant safety procedures, and enhanced personal protective equipment. Less than three weeks after the mandate was given, the HRRT was operational for a 12-week period during the first wave of COVID-19 in Ontario. HRRT members attended ~70% of calls requiring high risk procedures and were associated with improved quality of care indicators. No paramedics in the service contracted COVID-19 during the program.

The changing nature of healthcare education and delivery is such that clinicians will increasingly find themselves practicing in contexts that are physically and/or conceptually different from the settings in which they were trained, a practice that conflicts on some level with socio-cultural theories of learning that emphasize learning in context. Our objective was therefore to explore learning in 'professionally distant' contexts. Using paramedic education, where portions of training occur in hospital settings despite preparing students for out-of-hospital work, fifty-three informants (11 current students, 13 recent graduates, 16 paramedic program faculty and 13 program coordinators/directors) took part in five semi-structured focus groups. Participants reflected on the value and role of hospital placements in paramedic student development. All sessions were audio recorded, transcribed verbatim and analyzed using inductive thematic analysis. In this context six educational advantages and two challenges were identified when using professionally distant learning environments. Learning could still be associated with features such as (a) engagement through "authenticity", (b) technical skill development, (c) interpersonal skill development, (d) psychological resilience, (e) healthcare system knowledge and (f) scaffolding. Variability in learning and misalignment with learning goals were identified as potential threats. Learning environments that are professionally distant from eventual practice settings may prove meaningful by providing learners with foundational and preparatory learning experiences for competencies that may be transferrable. This suggests that where learning occurs may be less important than how the experience contributes to the learner's development and the meaning or value he/she derives from it.

Background: Bystander cardiopulmonary resuscitation (CPR) is an important determinant of survival from out-of-hospital cardiac arrest (OHCA), yet rates of bystander CPR are highly variable. In an effort to promote bystander CPR, the procedure has been streamlined, and ultrashort teaching modalities have been introduced. CPR has been increasingly reconceptualized as simple, safe, and easy to perform; however, current methods of CPR instruction may not adequately prepare lay rescuers for the various logistical, conceptual, and emotional challenges of resuscitating a victim of cardiac arrest. Methods and Results: We adopted a constructivist grounded theory methodology to qualitatively explore bystander CPR and invited lay rescuers who had recently (ie, within 1 week) intervened in an OHCA to participate in semistructured interviews and focus groups. We used constant comparative analysis until theoretical saturation to derive a midrange explanatory theory of bystander CPR. We constructed a 3-stage theoretical model describing a common experiential process for lay rescuer intervention in OHCA: Being called to act is disturbing, causing panic, shock, and disbelief that must ultimately be overcome. Taking action to save the victim is complicated by several misconceptions about cardiac arrest, where victims are mistakenly believed to be choking, and agonal respirations are misinterpreted to mean the victim is alive. Making sense of the experience is challenging, at least in the short term, where lay rescuers have to contend with self-doubt, unanswered questions, and uncomfortable emotional reactions to a traumatic event. Conclusions: Our study suggests that current CPR training programs may not adequately prepare lay rescuers for the reality of an OHCA and identifies several key knowledge gaps that should be addressed. The long-term psychological consequences of bystander intervention in OHCA remain poorly understood and warrant further study.

Background Non-clinical attributes are increasingly emphasised as an important factor in paramedic practice. However, the assessment of these attributes often lacks the evidence base to support it. Exploring the relationship between non-clinical attributes and clinical skills is also of theoretical and practical importance. Objective To first seek evidence of reliability and validity for the assessment of non-clinical attributes using the multiple mini-interview (MMI) in paramedic contexts and second, to explore the association between non-clinical attributes and clinical skills in paramedicine. Methods Entry to practice level paramedic candidates completed a 10-station MMI to assess non-clinical attributes on day 1 and a 10-station simulation-based assessment (SBA) of clinical skills on day 2. Both were assessed using different global rating scales. Our primary outcomes included MMI inter-station reliability (calculated using generalisability theory) and Pearson9s correlation between non-clinical attributes and clinically focused skills. Results 30 trainees completed the MMI and 26 of the 30 completed the SBA. Inter-station reliability for the MMI reached 0.77. Pearson9s correlations (disattenuated correlations in parentheses) between the overall MMI score and mean SBA global rating scores reached r=0.31 (r=0.48) and ranged by dimension from r=−0.11 (−0.17) (procedural skills) to r=0.54(r=0.83) (communication). Conclusions The MMI demonstrated evidence of reliability and validity for the assessment of non-clinical attributes in paramedic contexts. Non-clinical attributes and paramedic clinical skills are likely distinct but related constructs, each contributing to the construct of paramedic practice. Programmes of assessment should include both to ensure the construct of paramedic practice is adequately represented.

The objective of this study was to seek validity evidence for simulation-based assessments (SBA) of paramedics by asking to what extent the measurements obtained in SBA of clinical competence are associated with measurements obtained in actual paramedic contexts, with real patients.This prospective observational study involved analyzing the assessment of paramedic trainees at the entry-to-practice level in both simulation- and workplace-based settings. The SBA followed an OSCE structure involving full clinical cases from initial patient contact to transport or transfer of care. The workplace-based assessment (WBA) involved rating samples of clinical performance during real clinical encounters while assigned to an emergency medical service. For each candidate, both assessments were completed during a 3-week period at the end of their training. Raters in the SBA and WBA settings used the same paramedic-specific seven-dimension global rating scale. Reliability was calculated and decision studies were completed using generalizability theory. Associations between settings (overall and by dimension) were calculated using Pearson's correlation.A total of 49 paramedic trainees were assessed using both a SBA and WBA. The mean score in the SBA and WBA settings were 4.88 (SD = 0.68) and 5.39 (SD = 0.48), respectively, out of a possible 7. Reliability for the SBA and WBA settings reached 0.55 and 0.49, respectively. A decision study revealed 10 and 13 cases would be needed to reach a reliability of 0.7 for the SBA and WBA settings. Pearson correlation reached 0.37 (p = 0.01) between settings, which rose to 0.73 when controlling for imperfect reliability; five of seven dimensions (situation awareness, history gathering, patient assessment, decision making, and communication) reaching significance. Two dimensions (resource utilization and procedural skills) did not reach significance.For five of the seven dimensions believed to represent the construct of paramedic clinical performance, scores obtained in the SBA were associated with scores obtained in real clinical contexts with real patients. As SBAs are often used to infer clinical competence and predict future clinical performance, this study contributes validity evidence to support these claims as long as the importance of sampling performance broadly and extensively is appreciated and implemented.

Objective “Deliberate practice” and “feedback” are necessary for the development of expertise. We explored clinical performance in settings where these features are inconsistent or limited, hypothesizing that even in algorithmic domains of practice, clinical performance reformulates in ways that may threaten patient safety, and that experience fails to predict performance. Methods Paramedics participated in two recorded simulation sessions involving airway management, which were analyzed three ways: first, we identified variations in “decision paths” by coding the actions of the participants according to an airway management algorithm. Second, we identified cognitive schemas driving behavior using qualitative descriptive analysis. Third, clinical performances were evaluated using a global rating scale, checklist, and time to achieve ventilation; the relationship between experience and these metrics was assessed using Pearson’s correlation. Results Thirty participants completed a total of 59 simulations. Mean experience was 7.2 (SD=5.8) years. We observed highly variable practice patterns and identified idiosyncratic decision paths and schemas governing practice. We revealed problematic performance deficiencies related to situation awareness, decision making, and procedural skills. There was no association between experience and clinical performance (Scenario 1: r=0.13, p=0.47; Scenario 2: r=−0.10, p=0.58), or the number of errors (Scenario 1: r=.10, p=0.57; Scenario 2: r=0.25, p=0.17) or the time to achieve ventilation (Scenario 1: r=0.53, p=0.78; Scenario 2: r=0.27, p=0.15). Conclusion Clinical performance was highly variable when approaching an algorithmic problem, and procedural and cognitive errors were not attenuated by provider experience. These findings suggest reformulations of practice emerge in settings where feedback and deliberate practice are limited.

Since their introduction over 40 years ago, paramedics have been trained to deliver select advanced life support interventions in the community with the goal of reducing morbidity and mortality from cardiovascular disease and trauma. The ensuing decades witnessed a great deal of interest in paramedic care, with an exponential growth in prehospital resuscitation research. As part of the CJEM series on emergency medical services (EMS), we review recent prehospital research in out-of-hospital cardiac arrest and discuss how, in a novel departure from the origins of EMS, prehospital research is beginning to influence in-hospital care. We discuss emerging areas of study related to cardiopulmonary resuscitation (CPR) quality, therapeutic hypothermia, termination of resuscitation, and the use of end-tidal carbon dioxide measurement, as well as the subtle ripple effects that prehospital research is having on the broader understanding of the management of these critically ill patients.