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

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14 February 2023

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15 February 2023

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Abstract
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.
Keywords: 
Emergency Medical Services; paramedics; gender; diversity
Subject: 
Social Sciences  -   Sociology

1. Introduction

There is growing recognition of the importance of a diverse healthcare workforce as a means of promoting health equity 1. In order to be attuned to the health and social needs of patients, healthcare institutions need to be demographically reflective of the communities they serve 2. Paramedics are an important part of Canada’s healthcare infrastructure, with a role that is growing in both scope and complexity, but the profession has historically been male-dominated, both in the demography of its workforce and in its organizational culture 2.
Recent studies on the Emergency Medical Services (EMS) workforce in the United States (US) have shown that although the proportion of women and racial or ethnic minorities is increasing 3, participation in leadership roles remains low 2 - pointing to a ‘leaky pipeline’ effect. Focusing on gender specifically, women are estimated to make up less than 25% of EMS personnel providing care in the US 4. In Canada, the proportion of women in the Public Safety Professions (PSP) – an umbrella term that includes paramedics alongside police officers, firefighters, corrections workers, and security and intelligence officers, among others – is estimated at around 30% 5. Among paramedic specifically, participation by women is generally higher, estimated at approximately 38% nationally 6. Although recent estimates show more women are choosing paramedicine as a career 6, participation in leadership appears to lag behind, with one gray literature estimate suggesting that women hold just 5% of supervisory or managerial positions in Canada 7.
Unfortunately, women face a multitude of barriers to career advancement broadly and may face additional challenges within paramedicine, owing to its origins in the public safety professions. The organizational culture in policing and firefighting (for example) has been described in scholarship as ‘hyper masculine’ 8, with gender-based discrimination and workplace incivility being commonplace 9. In emulating other historically male-dominated professions, the organizational culture in paramedicine may create more subtle conditions that disadvantage women. Paramedics in Canada wear police-style uniforms, generally have hierarchical reporting structures, and adopt military-esque nomenclature (i.e., “commander” instead of “manager”, “platoon” to describe shift schedule rotations). These cultural artefacts may inadvertently perpetuate many of the same implicit biases that favor men that exist in the armed forces and broader public safety professions, making career advancement for women more challenging.
In contrast to recent investigations in the United States 3, 10, detailed demographic data on the paramedic workforce in Canada is sparse. Therefore, as part of a larger mental health study, our objective was to describe the demography of a single paramedic service and assess women’s participation in leadership roles.

2. Methods

Overview & Setting

A detailed accounting of the methods for this study has been described in an earlier publication 11. In brief, the data were drawn from an in-person mental health survey conducted during compulsory Continuing Medical Education (CME) sessions in a single paramedic service in Ontario, Canada. In Ontario, land ambulance and paramedic services are publicly funded, provided lower-tier municipal governments and are separate from police and fire services. Entry to practice education at the Primary Care Paramedic (PCP) certification requires a (typically two-year) community college diploma, with Advanced Care Paramedic (ACP) certification requiring an additional year of study. At the time of data collection, our study site 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.

Data Collection

As part of a larger investigation into the prevalence and risk factors for mental illness, paramedics attending CME completed a paper-based demographic questionnaire alongside a battery of clinically validated screening tools for various mental disorder symptom clusters. The demographic questionnaire inquired 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), provider classification (P/ACP) and current role within the service. Response options for gender included man, woman, transgender, or non-binary, with definitions and descriptive language drawn from guidelines advanced by the Canadian Institutes of Health Research.

Analysis

We used descriptive statistics to report on the demography of the workforce. Group differences were assessed using Analysis of Variance (ANOVA) and chi-square tests for continuous and categorical data, respectively. 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. In contrast to entry-to-practice recruitment, postings for supervisory positions prefer a university degree. We were therefore specifically interested in educational attainment and participation in leadership roles stratified by gender.
Ethics approval was provided by the Hamilton Integrated Research Ethics Board (HiREB protocol 7595). All participants provided informed consent.

3. Results

Between September 2019 through February 2020, a total of 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%.
Demographic data are presented in Table 1. In total, 60% of participants were men, with an average age of 34.5 (+/- 8.2) years and an average of 9.3 (+/- 0.4) years of experience. A small number (not reported to preserve anonymity) provided another, non-binary gender.
Compared with men, women were somewhat younger (33.6 vs. 35.1, p=0.02), had marginally less experience (8.4 vs. 9.7 years, p=0.02), were more likely to have completed university education (54% vs. 37%, Odds Ratio [OR] 2.02, 95% Compatibility Interval [CI] 1.45-2.83, p<0.001), but less likely to practice at the ACP certification (26% vs. 36%, OR 0.61, 95% CI 0.42-0.88, p=0.009). Our analysis also suggested women were less likely to work full-time (59% vs. 63%, OR 0.77, 95% CI 0.54-1.09) but the test did not reach significance at the 5% threshold (p=0.14).
Members in leadership positions accounted for 5% of survey participants. Compared with the workforce as a whole, participants in leadership positions were older (45 vs. 33 years, p<0.001), more experienced (20 vs. 8 years, p<0.001), somewhat less likely to have a university degree (40% vs. 44%, OR 0.85, 95% CI 0.40-1.79, p=0.662), but mostly male, with men (N=24) holding 80% of leadership roles. Compared to men, women were nearly 70% less likely to hold a leadership role (OR 0.36, 95% CI 0.14-0.90, p=0.02).

4. Discussion

Although we found a larger proportion of women paramedics than has been reported in similar estimates in the US 2-4, 10 or among public safety personnel in Canada 5, our analysis points to an underrepresentation in leadership positions. Despite women making up 40% of the active-duty paramedic workforce and being more likely to hold an undergraduate (50% vs. 35%), professional (1.7% vs. 0.5%), or graduate (2% vs. 1%) degree, women’s participation in supervisory and management roles was considerably less than that of men.
Having women in leadership roles contributes to greater diversity of thought, strengthening an organization’s capacity to solve complex problems 12, 13. Women often deploy transformational and collaborative approaches to leadership, and having women leaders has been shown to improve productivity, contribute to organizational resilience – particularly during times of crisis 14 – and enhance the health of the workforce 15. On the other hand, underrepresentation of women in leadership is problematic for several reasons. From a workforce health perspective, experiences of inequity can be devastating to the organizational culture of a workplace 16. For example, a recent study of 1.4 million Glassdoor reviews found that a toxic corporate culture was the single largest predictor of attrition 17, with gender inequality being one of the most influential factors of an outgoing employee’s assessment of the company 18.
Women face a number of widely recognized barriers to assuming leadership roles including a lack of visible role models and mentors 19; disproportionate responsibilities in the home20; actual or perceived exclusion from social and networking events 12, 21-24; sexual harassment and discrimination 15; and gender biases that disadvantage leadership styles more typically associated with women 15. In particular, the lack of visible role models makes it literally and metaphorically harder for women to ‘see themselves’ in leadership roles - a phenomenon that has been widely documented 15, 21. In paramedicine, women undoubtedly face many of the same barriers, however, there may well be additional challenges to overcome. Public safety professions – most notably police and fire – have been described in research as ‘blue collar’ 25 and ‘hyper masculine’ 8 and artifacts of an organizational culture that favors men may create real or perceived barriers to career advancement for women. 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 the profession. In that respect, participatory action and qualitative research approaches have much potential both to shed light on the problem and develop creative solutions.

Limitations

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 for reasons that have been explained elsewhere 11. This necessarily limits the scope of our analysis to gender but should not be taken to suggest that race, ethnicity, and other identity dimensions are less relevant or important. Finally, we also acknowledge that our data is now two years old and limited to a single site. More recent data from multiple sites – ideally on a national scale – would be helpful.

5. Conclusion

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

Author Contributions

JM was responsible for the design of the study, collection, analysis, and interpretation of data, and drafting of the manuscript. SS and EAD contributed to the collection and interpretation of data and content of the manuscript. DAB contributed to the preparation and critical review of the manuscript. All authors approved the final version prior to submission.

Funding

This study received funding a catalyst grant from the Canadian Institutes of Health Research (CIHR) to study post-traumatic stress injuries among public safety personnel (competition number 201809PPS). Peel Regional Paramedic Services provided in-kind support during data collection and investigator funding for JM, SS, and DAB.

Conflicts of Interest

Authors JM, SS, and DAB are employed by Peel Regional Paramedic Services.

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Table 1. Detailed participant demographics. SD = Standard Deviation. *Counts <5 not reported to preserve anonymity.
Table 1. Detailed participant demographics. SD = Standard Deviation. *Counts <5 not reported to preserve anonymity.
Parameter Men Women Sig.
Mean SD Mean SD
Age (years) 35.2 8.5 33.6 7.5 0.021
Experience (years) 9.8 7.6 8.4 6.9 0.023
Education N % N %
College Certificate 27 7.6% 13 5.6% <0.001
College Diploma 196 55.4% 93 40.1%
Undergraduate Degree 125 35.3% 117 50.4%
Professional Degree -* 0.6% -* 1.7%
Graduate Degree -* 1.1% 5 2.2%
Any University 131 37% 126 54.3% <0.001
Employment Classification
Part-Time or Temporary Contract 109 30.8% 85 36.6% 0.148
Full-Time 244 68.9% 147 63.4%
Clinical Certification
Primary Care Paramedic 226 63.8% 174 74.1% 0.009
Advanced Care Paramedic 128 36.2% 60 25.9%
Role in Service
Regular / Front-Line 327 92.4% 223 96.1% 0.006
Rapid Response Unit 46 13% 22 9.5%
Tactical 16 4.5% -* 0.4%
Community Paramedicine -* 0.3% -* 1.3%
Peer Support Team 16 4.5% 13 5.6% 0.554
Leadership Role
Any Leadership Position 24 7.3% 6 2.6% 0.024
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Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.

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