Hazard Flagging as a Risk Mitigation Strategy for Violence against Emergency Medical Services.

Paramedics are increasingly being subjected to violence, creating the potential for significant physical and psychological harm. Where a patient has a history of violent behavior, hazard flags-applied either to the individual, their residential address, or phone number-can alert paramedics to the possibility of violence, potentially reducing the risk of injury. Leveraging a novel violence reporting process embedded in the electronic patient care record, we reviewed violence reports filed over a thirteen-month period since its inception in February 2021 to assess the effectiveness of hazard flagging as a potential risk mitigation strategy. Upon reviewing a report, paramedic supervisors can generate a hazard flag if recurrent violent behavior from the patient is anticipated. In all, 502 violence reports were filed, for which paramedic supervisors generated hazard flags in 20% of cases (n = 99). In general, cases were not flagged either because the incident occurred at a location not amenable to flagging or because the supervisors felt that a hazard flag was not warranted based on the details in the report. Hazard flagging was associated with an increased risk of violence during subsequent paramedic attendance (Odds Ratio [OR] 6.21, p < 0.001). Nevertheless, the process appears to reliably identify persons who may be violent towards paramedics.

Sexist, Racist, and Homophobic Violence against Paramedics in a Single Canadian Site.

Violence against paramedics is widely recognized as a serious, but underreported, problem. While injurious physical attacks on paramedics are generally reported, non-physical violence is less likely to be documented. Verbal abuse can be very distressing, particularly if the harassment targets personal or cultural identities, such as race, ethnicity, gender, or sexual orientation. Leveraging a novel, point-of-event reporting process, our objective was to estimate the prevalence of harassment on identity grounds against paramedics in a single paramedic service in Ontario, Canada, and assess its potentially differential impact on emotional distress. In an analysis of 502 reports filed between 1 February 2021 and 28 February 2022, two paramedic supervisors independently coded the free-text narrative descriptions of violent encounters for themes suggestive of sexism, racism, and homophobia. We achieved high inter-rater agreement across the dimensions (k = 0.73-0.83), and after resolving discrepant cases, we found that one in four violent reports documented abuse on at least one of the identity grounds. In these cases, paramedics were 60% more likely to indicate being emotionally distressed than for other forms of violence. Our findings offer unique insight into the type of vitriol paramedics experience over the course of their work and its potential for psychological harm.

Paramedic Willingness to Report Violence Following the Introduction of a Novel, Point-of-Event Reporting Process in a Single Canadian Paramedic Service.

Violence against paramedics is increasingly recognized as an important occupational health problem, but pervasive and institutionalized underreporting hinders efforts at risk mitigation. Earlier research has shown that the organizational culture within paramedicine may contribute to underreporting, and researchers have recommended involving paramedics in the development of violence prevention policies, including reporting systems. Eighteen months after the launch of a new violence reporting system in Peel Region, Ontario, Canada, we surveyed paramedics about their experiences reporting violent encounters. Our objectives were to assess their willingness to report violence and explore factors that influence their decisions to file a report. Between September and December 2022, a total of 204 (33% of eligible) paramedics chose to participate, of whom 67% (N = 137) had experienced violence since the launch of the new reporting process, with 83% (N = 114) reporting the incidents at least some of the time. After thematically analyzing free-text survey responses, we found that the participants cited the accessibility of the new reporting process and the desire to promote accountability among perpetrators while contributing to a safer workplace as motivating factors. Their decisions to file a report, however, could be influenced by the perceived 'volitionality' and severity of the violent encounters, particularly in the context of (un)supportive co-workers and supervisors. Ultimately, the participants' belief that the report would lead to meaningful change within the service was a key driver of reporting behavior.

Prevalence and Characteristics of Violence against Paramedics in a Single Canadian Site.

Violence against paramedics has been described as a 'serious public health problem' but one that remains 'vastly underreported', owing to an organizational culture that stigmatizes reporting-hindering efforts at risk mitigation in addition to creating a gap in research. Leveraging a novel reporting process developed after extensive stakeholder consultation and embedded within the electronic patient care record, our objective was to provide a descriptive profile of violence against paramedics in a single paramedic service in Ontario, Canada. Between 1 February 2021 and 31 January 2023, a total of 374 paramedics in Peel Region (48% of the workforce) generated 941 violence reports, of which 40% documented physical (n = 364) or sexual (n = 19) assault. The violence was typically perpetrated by patients (78%) and primarily took place at the scene of the 9-1-1 call (47%); however, violent behavior frequently persisted or recurred while in transit to hospital and after arrival. Collectively, mental health, alcohol, or drug use were listed as contributing circumstances in 83% of the violence reports. In all, 81 paramedics were physically harmed because of an assault. On average, our data correspond to a paramedic filing a violence report every 18 h, being physically assaulted every 46 h, and injured every 9 days.

Women's Participation in Leadership Roles in a Single Canadian Paramedic Service.

INTRODUCTION: Like other public safety professions, paramedicine has historically been a male-dominated occupation. Although women are increasingly choosing paramedicine as a career, participation in leadership roles remains limited. Drawing on data from a 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 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, educational achievement, clinician level (e.g., primary vs. advanced care), and participation in formal leadership roles along self-reported gender lines. RESULTS: Out of 607 paramedics attending, 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 university degrees (odds ratio [OR] 2.02, 95% compatibility interval [CI] 1.45-2.83), but almost half as likely to practice at the advanced care paramedic level (OR 0.61, 95% CI 0.42-0.88), and potentially less likely to be employed full-time (OR 0.77, 95% CI 0.54-1.09). Women were nearly 70% less likely to hold leadership roles in the service compared to men (OR 0.36, 95% CI 0.14-0.90), occupying 20% of leadership positions. CONCLUSION: Although paramedicine is witnessing an encouraging shift in the demography of its workforce, our results point to a potential under-representation of women in leadership roles. Future research should focus on identifying and ameliorating barriers to career advancement among women and other historically underrepresented people.

Violence Against Paramedics: Protocol for Evaluating 2 Years of Reports Through a Novel, Point-of-Event Reporting Process.

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 IDENTIFIER (IRRID): DERR1-10.2196/37636.

Mental Disorder Symptoms and the Relationship with Resilience among Paramedics in a Single Canadian Site.

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.

Protected 911: Development, Implementation, and Evaluation of a Prehospital COVID-19 High-Risk Response Team.

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.

Role Identity, Dissonance, and Distress among Paramedics.

Role identity theory describes the purpose and meaning in life that comes, in part, from occupying social roles. While robustly linked to health and wellbeing, this may become unideal when an individual is unable to fulfill the perceived requirements of an especially salient role in the manner 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 wellbeing, 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.

"Please. Don't. Die.": A Grounded Theory Study of Bystander Cardiopulmonary Resuscitation.

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.

Learning in professionally 'distant' contexts: opportunities and challenges.

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.

Reformulations of practice: beyond experience in paramedic airway management.

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.

The impact of prehospital resuscitation research on in-hospital care.

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.

Assessment of non-clinical attributes in paramedicine using multiple mini-interviews.

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 Pearson's 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. Pearson's 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.

Simulation-based assessment of paramedics and performance in real clinical contexts.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.