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. Our objective was to qualitatively explore paramedics’ experience with violence, with particular emphasis on understanding how organizational culture contributes to under-reporting. Approach We 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%). We 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 While the extant research has indicated that underreporting is a problem, our findings shed light on why – a critical first step in addressing what has been described as a serious public health problem.

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.

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.

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 February 1, 2021, through January 31, 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 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 hours, being physically assaulted every 46 hours, and injured every 9 days.

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 February 1, 2021, through February 28, 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 interrater agreement across the dimensions (k=0.73-0.83), and after resolving discrepant cases, we found that 1 in 4 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 in the course of their work and its potential for psychological harm.

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 comprehensive violence reporting system in Peel Region, Ontario, Canada, we surveyed paramedics about their willingness to report violent encounters. 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. In choosing to report, 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.

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 2021to 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