Women’s Participation in Leadership Roles in a Single Canadian Paramedic Service

Abstract 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.


Introduction
There is growing recognition of the importance of a diverse health care workforce as a means of promoting health equity (1).To be attuned to the health and social needs of patients, health care institutions should be demographically reflective of the communities they serve (2).
Although recent research on the demography of the emergency medical services (EMS) workforce in the United States (US) has shown that the proportion of women is increasing (3), participation in leadership roles remains low (2), potentially pointing to a 'leaky pipeline' effect.In Canada, the proportion of women in the public safety professionsan umbrella term that includes paramedics alongside police officers, firefighters, and othersis estimated at around 30% (4), but disaggregated data are rare.A gray literature estimate suggests that women hold just 5% of supervisory or managerial positions in Canada (5), indicating a potential underrepresentation of women in paramedic services leadership.
Unfortunately, women face a multitude of barriers to career advancement broadly (6), and may face similar challenges within paramedicine.Therefore, as a preliminary study as part of an emerging research program in Ontario, our objective was to describe the demography of a single paramedic service and assess the participation of women in leadership roles.

Study Design & Setting
This is a secondary analysis of data drawn from a comprehensive in-person mental health survey conducted during compulsory continuing medical education (CME) sessions in a single, large, urban, paramedic service in Ontario, Canada (7).
In Ontario, land ambulance paramedic services are publicly funded, provided by lower-tier municipal governments, and are typically separate from police and fire services.Entry to practice education at the primary care paramedic (PCP) certification requires a (usually 2-year) community college diploma, with advanced care paramedic (ACP) certification requiring an additional year of study.At the time of data collection, the service employed 714 paramedics who responded to an average of 130,000 emergency calls per year, making the service the second largest in the province by staffing and caseload.
Ethics approval was provided by the Hamilton Integrated Research Ethics Board (HiREB protocol 7595).All participants provided informed consent.

Data Collection
Paramedics in our study site are required to attend two standardized CME days per year (held in the spring and fall).Paramedics are rostered on a scheduled day off and attend each session once.As part of a larger mental health study, paramedics attending the fall 2019 to winter 2020 CME were invited to complete a paper-based demographic questionnaire alongside a battery of clinically validated screening tools for various psychiatric disorder symptom clusters.The demographic questionnairethe sole source of data for the present studyinquired about the participant's gender, age, highest education completed (e.g., college diploma, undergraduate degree, graduate degree), years of experience, employment (e.g., part vs. full-time), clinician classification (PCP vs. ACP), and current role (e.g., front line, supervisory, education) within the service (Supplemental Figure 1).
The principal investigator (JM) attended each CME day to explain the goals of the study and answer questions from attendees.Paramedics each received an opaque envelope containing the survey materials and a $10 (CAD) Tim Horton's gift card.They were given 15 min of protected time to complete the survey and deposit the sealed envelopes in a locked drop box at the front of the classroom.Attendees who did not want to participate could leave the room or return an unfilled survey, but were free to keep the gift card.

Measures/Outcomes
Response options for gender included man, woman, transgender, or non-binary, with definitions and descriptive language drawn from guidelines advanced by the Canadian Institutes for Health Research.We defined a 'leadership role' as a current assignment in a superintendent (supervisor), commander (manager), or senior administration (e.g., department head, deputy chief) position, later collapsed to a dichotomous leadership variable due to small sub-group sizes.Although entry-to-practice education for paramedics in Ontario requires each applicant to have completed a community college diploma, supervisory positions prefer a university degree.We were therefore specifically interested in educational attainment (highest completed) and participation in leadership roles stratified by gender.

Statistical Analysis
We used descriptive statistics to report on the demography of the workforce, including measures of central tendency and dispersion for continuous variables and counts and percentages for categorial variables.Age and experience were measured in complete years and assessed for normality using plots alongside skewness and kurtosis tests stratified by gender.Group differences were assessed using analysis of variance (ANOVA) and chi-square tests for continuous and categorical data, respectively.

Results
Between September 2019 through February 2020, 607 paramedics attended CME.We received 600 completed surveys, of which 11 were excluded for incomplete data, leaving a final sample of 589 participants and a response rate of 97% (Figure 1).
Demographic data are presented in Table 1.Our sample included 354 men and 232 women, making up 60% and 39% of the sample, respectively.Two participants provided another, non-binary gender and were omitted from subsequent analyses.

Discussion
Although we found a larger proportion of women paramedics than has been reported in similar estimates in the US (2,3,8,9) or among public safety personnel in Canada (4), our analysis points toward an underrepresentation of women in leadership positions.Having women in leadership roles contributes to greater diversity of thought.Women often deploy transformational and collaborative approaches to leadership, and having women leaders has been shown to improve productivity, contribute to organizational resilienceparticularly during times of crisisand enhance the health of the workforce (10).On the other hand, underrepresentation of women in leadership can negatively affect the organizational culture of a workplace (11).
The reasons for the underrepresentation we observed are not immediately clear; however, our findings parallel a larger body of work illustrating similar gender gaps in leadership structures in health care (10,12), including in EMS (2,8,13,14).Women face a number of barriers to assuming leadership roles including a lack of visible role models and mentors; disproportionate responsibilities in the home; exclusion (perceived or real) from social and networking events; sexual harassment and discrimination; and gender biases that prefer more typically masculine approaches to leadership (10).In paramedicine, women may face many of the same barriers, but there may be additional challenges to overcome, owing to the vocation's origins in the public safety professions.Future research should focus on building a better understanding of the demography of the paramedic workforce in Canada and identifying barriers to career advancement for women and other historically underrepresented people that may be unique to paramedicine.In that respect, participatory action and qualitative research approaches have much potential both to shed light on the problem and develop creative solutions.
Our findings should be interpreted within the context of certain limitations.First, our survey excluded 107 paramedics on leave during the CME sessions, including some in leadership roles.Second, we did not collect data on race or ethnicity in the survey; due to the relative homogeneity of our sample we would have been underpowered to detect potentially important relationships between certain identity grounds and our primary outcome of mental illness so we made an a priori decision to limit data collection to categories that we could meaningfully assess.This necessarily limits the scope of our analysis specifically to gender, but should not be taken to suggest that other identity dimensions are less relevant or important.Third, completing the surveys in a group setting might have made individual participants feel observed, potentially introducing a degree of response bias.Finally, we also acknowledge that our data are now 2 years old and limited to a single site.More recent data from multiple sitesideally on a national scalewould be welcome.

Conclusion
Despite comprising 40% of the active-duty paramedic workforce, and having comparable experience and higher rates of university education, women were underrepresented in paramedic service leadership in our study.Our preliminary findings should invite further, action-oriented research on the topic in Canada.

Disclosure Statement
Authors JM, SS, & DAB are employed by Peel Regional Paramedic Services and completed this study as part of a broader psychological health and safety research program sponsored by the Region of Peel.Author EAD reports no interests to disclose.

Table 1 .
Detailed participant demographics.Indicates p-value corresponds to main effects of the group in multi-level variable.Post-hoc analyses not performed due to small group sizes.Education levels were collapsed into a composite variable for "any university" (undergraduate, professional, or graduate degree vs. college certificate or diploma).