Examining the quality of work-life of paramedics in northern Ontario,Canada: A cross-sectional study

Abstract

BACKGROUND:

Paramedics are exposed to multiple stressors in the workplace. They are more likely to develop occupational-related stress conditions compared to other occupations. This study focused on understanding the factors affecting QoWL of paramedics in northern Ontario, Canada; a particular focus was on understanding the personal and organizational factors, such as practicing community paramedicine (CP), which may be associated with Quality of Work Life (QoWL).

METHODS:

Paramedic QoWL was assessed using an online survey that was distributed to approximately 879 paramedics across northern Ontario. The survey included the 23-Item Work- Related Quality of Work Life Scale. Data analysis involved linear regressions with nine predictor variables deemed to be related to QoWL for paramedics with QoWL and its six subscales as dependent variables. Multiple linear regressions were used to assess the personal and organizational factors, such as practicing of CP, which predicted QoWL.

RESULTS:

One hundred and ninety-seven paramedics completed the questionnaire. Overall, the mean QoWL score of all paramedic participants was 73.99, and this average compared to relevant published norms for other occupations. Factors that were most associated with higher QoWL were, experience practicing CP (p < 0.05), number of sick days/year (p < 0.01), and higher self- rated mental health (p < 0.001).

CONCLUSIONS:

Higher paramedic QoWL appears to be associated with many factors such as number of sick days per year, self-rated mental health, and participation in CP. EMS organizations should consider establishing necessary workplace health promotion strategies that are targeted at improving QoWL for paramedics.

Keywords

Paramedics quality of work life rural northern Canada

1 Background

A new community-based health care model, community paramedicine (CP), was recently introduced throughout Ontario [1]. CP in northern Ontario involves paramedics proactively practicing health promotion strategies to improve the health and well-being of patients [2]. CP practice usually involves situations where paramedics provide preventative non-emergency care, in non-ambulatory settings, to frequent users of the dispatch ambulance system. The goal of CP is to reduce unnecessary emergency dispatch calls and hospital emergency department visits and assist in addressing health service gaps and providing timely care for patients in need [1]. Thus, paramedics who practice CP in northern Ontario regularly visit patients in their homes or meet with several patients at a time during scheduled wellness clinics at convenient locations such as community centres or apartment complexes.

Paramedicine in rural and northern Ontario, Canada, is different from paramedicine in southern Ontario due to variations in geographic and cultural characteristics. Geographically, northern Ontario is much larger, more rural, and less populated than Southern Ontario [2]. According to the Ministry of Health and Long-Term Care [1], rural communities are defined as “those with a population of less than 30,000 that are greater than 30 minutes away in travel time from a community with a population of more than 30,000” [3]. Due to the expansive geography of northern Ontario, paramedics in rural areas are often stationed in isolated locations, and they are often required to travel much longer distances (sometimes hundreds of kilometres) to respond to medical emergencies and then transport patients to hospitals, which adds to their job demands.

Northern Ontario contains 90% of Ontario’s land mass [4] and approximately 6% of the population [5, 6]. Therefore, geography and population density are significant factors that have propelled different health priorities across northern Ontario [7] rather than those focused on large urban population centers and systems [8]. The large geography and relative small spread out population of northern Ontario results in challenges to health service delivery including paramedic services. Residents in northern Ontario experience poorer health and larger health disparities than the rest of the province of Ontario [9, 10]. Poor health outcomes in northern Ontario are influenced by limitations to social and economic opportunities (e.g., housing, education) [10].

An increasing number of sources identify the susceptibility of paramedics to occupational- related stress [1 , 11–13]. Compared to their urban counterparts, factors associated with occupational-related stress of rural paramedics are forced-rural posting, isolation/lack of support, unfavourable work patterns, loss of skill competency, and knowing the patient [14]. Also, other factors affect the psychological well-being of paramedics related to their organizational and personal lives. Hamilton states that “many rural healthcare staff share common stressors that are linked to a lack of social and organizational support, and the need for a better work-life balance” [14]. Thus, occupational-related stress is also related to paramedics’ quality of life due to increased psychological demands [15]. The purpose of this paper is to explore relationships between organizational and personal factors of paramedics in their lives at work.

Paramedics experience greater injury rates in the workplace than the general working population and other health care professionals [16]. Compared to other stressful occupation roles such as police, nurses, and firefighters, paramedics are ranked first regarding their work’s negative impacts on their physical well-being [12] The literature demonstrates that paramedics experience higher stress levels than other occupations, which is even more pronounced for rural paramedics [14, 17]. Cydulka reported that “88.7% of paramedics felt that their job was stressful and felt psychologically worn out after work” [18].

Workplace stress can be understood as a function of demanding a person’s job and how much control (discretion, authority, or decision latitude) the person has over their responsibilities [19]. There are several physical, mental, intellectual, behavioural, and organizational effects related to high-stress levels. In terms of physical effects, stress has been linked to reduced cognitive function, depressed immune system, increased blood pressure, and increased diabetes [20]. High levels of stress have been linked to psychological morbidities [21]. According to Regehr and Millar, occupational stressors also significantly affect the quality of interpersonal relationships within the family itself [12]. Some of these stressors are similar to those experienced by other health professionals who have contact with large numbers of patients and the public; and who are responsible for a person’s life and well-being [22]. Additionally, paramedics work in environments that may be dangerous and unfamiliar, such as roadways and accident sites, and bystanders often judge them on their job performance [22 –24].

A white paper released by the Paramedic Chiefs of Canada outlined paramedics’ status regarding operational stress injury. Operational stress injury (OSI) is the “non-medical term used to describe psychological problems resulting from mentally and/or emotionally traumatic circumstances” [11]. Forms of OSI for paramedics include critical incident stress, anxiety and depression, compassion fatigue, post-traumatic stress disorder, substance abuse, job burnout, and suicide [11]. Out of all first responders in Canada, paramedics experience the highest rates of PTSD (25.5%) compared to firefighters (17.3%) and police (7.6%) [25]. According to the Government of Ontario, due to the alarming rates of PTSD associated with paramedics and other first responders, recent legislation permits paramedics and other first responders to make disability claims due to PTSD caused by the workplace under the First Responders Act (Post- Traumatic Stress Disorder) 2016, S.O. 2016, c. 4 –Bill 163 [26].

The prevalence of PTSD in the paramedic population is also much higher than Canada’s general population. In 2016, approximately 25.5% paramedics suffered PTSD in Canada compared to 9.6% of the national population [25]. In 2016, paramedics also had the highest suicide rates compared to all first responder personnel in Canada. Compared to the Canadian population, paramedics also have much higher rates of suicides, with 56.7 per 100,000 paramedics committing suicide compared to 17.30 per 100,000 for Canadian males and 5.40 per 100,000 for Canadian females [25].

In response to this, in April 2017, the Ontario Ministry of Labour (MOL) created a mandatory requirement for all emergency service providers (EMS, fire, and police) to submit PTSD Prevention Plans to the Ministry of Labour [27]. The purpose of this requirement was not only focused on prevention but also to ensure first responders had access to resources if they were experiencing PTSD or any other mental illness. Due to high rates of PTSD amongst emergency workers, including paramedics, it is deemed necessary for paramedics to receive appropriate interventions to mitigate poor psychosocial well-being [28].

Quality of work life (QoWL) is an important construct that is impacted by OSI and PTSD. It has multiple definitions in the literature, however, Easton et al. state that several constructs relate to of QoWL, and they vary according to the theoretical stance of researchers [29]. Easton et al. claim that the conceptualization of QoWL includes stress and psychological well-being at work, but agreement on what else should be included among key concepts has yet to be determined [29]. Essentially, a higher QoWL is associated with greater happiness and is beneficial for an employee regarding both psychological and physical well-being in an occupational setting [30, 31]. For the purpose of this study, QoWL was defined as how an occupation is beneficial for the well-being of an individual and how the employee would self- evaluate their occupation [15].

The Job-Demand Control Framework [JDCF] [19], was used as a theoretical framework to inform this study because of the similar constructs that the JDCF and QoWL share. The JDCF contains two main constructs: job demand (stressors) and job control (job duty discretion), which are theoretically similar to the stress at work and control at work constructs within QoWL. This framework was used to provide further insight into the findings related to describing any potential relationships between QoWL and CP. This form of practice presents more opportunity for leniency in job duties than conventional paramedicine, which, theoretically, may relate to stress at work. Several relevant study using the JDCF concluded that high-strain jobs have a combination of high psychological demands and low-decision latitude, which leads to psychological and physical stress [32 –34]. When workers experience low control in their job, anxiety, fatigue, depression, and physical illness [32].

Paramedicine is one of the most susceptible occupations for poor mental health, and there is a gap in research related to understanding the relevant factors related to QoWL for paramedics, especially those practicing in rural areas. This is especially important given the recent introduction of CP in Ontario, representing a change in some paramedics’ responsibilities and operational role. Thus, this exploratory study was designed to investigate the factors related to QoWL of paramedics in northern Ontario and addressed the following research questions:

What personal and organizational factors affect the QoWL of paramedics in northern Ontario?

Does experience practicing CP affect paramedic QoWL?

2 Methods

Data was collected using an online survey instrument that was developed by researchers from the Centre for Rural and Northern Health Research at Laurentian University in Sudbury, Ontario, Canada. The survey was developed to assess paramedic QoWL and evaluate pilot CP programs from paramedics’ perspective. Thus, a subset of the survey data, related to paramedic QoWL, was used for this study; the remaining data related to the CP evaluation will be reported elsewhere.

2.1 Setting and population

This study used self-report methods of paramedics working in northern Ontario designed to determine which personal and organizational factors were associated with QoWL, including experience practicing CP. This study’s region included several geographically large rural and urban regions in Northeast and Northwest Ontario, Canada that contain paramedic services coordinated through municipalities and/or District Service Boards (DSB’s). The majority of northern Ontario contains regions where population density is low and where many small communities are located several hundred kilometers away from the nearest hospitals [2]. These DSB’s are service management organizations created by the provincial government to oversee and coordinate a host of municipal managed programs such as social services (i.e. social housing, children’s services, and Ontario Works) and emergency medical services (EMSs), for geographically larger rural regions. The participants in this study consisted of primary care paramedics (PCPs) and advanced care paramedics (ACPs) working for eight EMS providers. The majority of these services provide pre-hospital emergency care in geographically large districts compared to more urban EMS providers in Southern Ontario. Three of the EMS providers also service urban centres with higher populations, higher call volumes, and shorter transport distances to local hospitals within each city. The majority of the other communities within these EMS providers’ service areas are rural and are dispersed across Northeastern and Northwestern Ontario.

The CP programs in six of the eight northern districts involved in this study are relatively unique in that CP is practiced with on-duty paramedics; two CP programs use dedicated paramedic practicing CP. Figure 2 in Chapter 2 contains a map of the service areas for the eight participating EMS providers.

2.2 Data collection

This study’s data was collected using an online survey instrument available to paramedics employed in eight EMS districts. The survey collected demographic information, attitudinal perspectives, and responses to the 23-item Work-Related Quality of Life or WRQoL scale [29]. There were 104 separate items/questions involving both multiple-choice and open-ended questions. The survey was available to the paramedics via an online link to the REDCap (Research Electronic Data Capture) software, a secure web-based application designed to support data capture for research studies [35]. Data was stored on a secure server at Laurentian University. The survey items were developed by members of the research team and modified from original items provided by the Ministry of Health and Long-Term Care for use in the evaluation of pilot CP programs in the province. A modified approach to Dillman’s Mail and Internet Design method was used to maximize response rate and minimize respondent bias. Participation by paramedics was voluntary, anonymous, and initiated by an e-mail invitation from the research team containing a link to the online survey. Every participant in the study completed an informed consent form before participating in the study. The email was then forwarded to paramedics employed by the eight EMS providers by either the EMS Chief or a Commander. Two reminder e-mails were sent. The entire data collection period occurred between November 2016 and February 2017. Ethical approval was obtained from the Laurentian University Research Ethics Board.

2.3 Survey instrument and scale characteristics

The following descriptive data were collected on the survey: age, hours worked per week, the language of services offered, education level, sex, years of service, employment status (full-time or part-time), rural (population < 30,000) vs. urban (population > 30,000) work status, self-perceived physical health, EMS provider/district, LHIN geographical area (Northeast or Northwest regions of northern Ontario) number of sick days/year, certification level, and whether or not they participated in a CP program in their district.

The scale used to measure QoWL, was the 23-Item Work-related Quality of Life (WRQoL) scale developed by Van Laar, Edwards, and Easton [15]. The WRQoL was deemed most appropriate because it is a holistic measure of the degree of work-related stress that may affect a person’s psychological well-being, and it was used with measuring QoWL of nurses [30, 36] and police officers [29]. The WRoQL contains six factors, or sub-scales, that measure components of work-related quality of work-life that used the United Kingdon National Health Service for reference norms [15]: 1) Career and Job Satisfaction (JCS): Measures overall satisfaction experienced with the participant’s job. Scale norm = 6 (min) to 36 (max); 2) Working Conditions (WCS): Measures items specific to the physical working environment and the accessibility and availability of necessary equipment. Scale norm = 3 (min) to 15 (max); 3) General Well-Being (GWB): Measures important factors of physical and psychological well-being (e.g. happiness) of the participant. Scale norm = 6 (min) to 30 (max); 4) Home-Work Interface (HWI): Measures how well the participant’s organization respects and assists them with respect to their work and home life balance. Scale norm = 3 (min) to 15 (max); 5) Stress at Work (SAW): Measures the work- related demands/stressors experienced by the participant in terms of whether they were stressful or acceptable. Higher SAW scores indicate lower levels of stress as this item was reverse- coded. Scale norm = 2 (min) to 10 (max); 6) Control at Work (CAW): Measures the degree to which the participant can contribute to decision-making in the workplace. Scale norm = 3 (min) to 15 (max).

The WRQoL uses a 5-point Likert scale that has the following response categories: strongly disagree = 1, disagree = 2, neutral = 3, agree = 4, and strongly agree = 5. The summary scores from each survey were calculated as the mean between the ranges of 1.00 to 5.00 for an overall mean summary score for WRQoL and mean scores for each of the six factors. The maximum score of the WRQoL is 115 [15]. This scale has demonstrated strong psychometric properties with an overall Cronbach’s alpha score of α= 0.91 [29], and it has been validated with the following psychometric scales: GHQ-12 General Health Questionnaire [37], Warr Job Satisfaction Scale [38], Warr Job Related Well-being Anxiety-Contentment Scale, Work Locus of Control [39], GSES Generalised Self-Efficacy Scale [40], and the TMMS Emotional Intelligence Scale [41]. The reference group for interpreting the scale results was from the United Kingdom National Health Service employees who were employed at United Kingdom hospitals and primary care centres.

2.4 Data analyses

The data analyses were performed using IBM SPSS [42] (IBM Corp., Armonk, NY, USA). Descriptive statistics were obtained for demographic data. Closed-ended responses from the WRQoL from the survey were coded between 1 (low) and 5 (high). Overall, QoWL and six sub-scale mean scores were calculated. Seven multiple linear regressions were performed using personal and organizational independent variables (sex, physical health, mental health, years employed, sick days/year, full- time status, CP experience, EMS provider worked for, and rural work location) as predictors of QoWL and the six subscales (JCS, WCS, GWB, HWI, SAW, and CAW) as dependent variables. The following demographic characteristics were used as independent variables and coded as the following:

2.4.1 Personal factors

Sex: Male (= 0) or female (= 1).

General Health: Self-rated status of paramedic physical health/well-being (from 1 = strongly disagree to 5 = strongly agree) from the General Health Questionnaire. Higher scores on the measure indicate better general health.

Mental Health: Self-rated status of paramedics mental health/well-being (from 1 = strongly disagree to 5 = strongly agree). Higher scores on the measure indicate better mental health.

Years Employed: The number of years the participant has been employed as a PCP, ACP, or CCP (1 = 0 to 9.9 years, 2 = 10 to 19 years, 3 = 20 to 29 years, 4 = 30 + years).

Sick days/year: Number of sick days the participant has been absent from work due to injury/illness in the past 12 months of survey distribution (1 = no sick days, 2 = 1 to 5 sick days, 3 = 6 to 10 sick days, 4 = 11 to 15 sick days, 5 = more than 15 sick days).

2.4.2 Organizational factors

Full-time: The paramedic’s employment status at their respective employer (1 = full-time or 0 = part-time).

CP Experience: Self-rated measure on the degree of participation/experience in a CP problem for their respective EMS provider (1 = CP experience and 0 = no CP experience).

EMS Service with CP: One of eight potential EMS providers where the paramedic was employed had a formal CP pilot program (0 = No, 1 = Yes).

Rural: Primary population size of the region and/or municipality where the paramedic spends most of their hours worked. Rural defined by a population of 29,999 or more and urban defined by a population of 30,000 or more (0 = urban and 1 = rural).

Due to this QoWL study’s explorative nature, a less conservative alpha level of 0.1 was used to detect statistically significant relationships in the data [43]. Missing data points were addressed for three records where subscale means were imputed for the missing values [44].

The independent variables (personal and organizational factors) were used as predictive factors in seven independent multiple linear regressions with QoWL summary scores and the six subscale summary scores as separate dependent variables to determine if there were any relationships. The independent R² coefficient indicated the proportion of variance explained by the linear regression models. Beta values and standard error of the mean values were reported for the independent multiple linear regression results.

3 Results

Out of the 879 paramedics who were eligible to complete the survey, there were 197 who completed the WRQoL, yielding a response rate of 22.0%. The mean age of the sample was 38.1 years (SD = 11.85), 71.6% (n = 140) were male, and the average years employed was 12.6 (SD = 9.71). Of the 197 paramedics who completed the WRQoL, there were (70.7%) (n = 139) of the paramedic survey population employed full-time and 29.3% (n = 58) employed part-time/casual or on modified duty. There were 43.7% (n = 86) of paramedics who practiced CP. The descriptive characteristics of the sample are summarized in Table 1.

Table 1
Characteristics of paramedic participants

Category % Total (n = 197)

Sex

Male 71.6 (140)

Female 28.4 (57)

Age

20–35 47.0 (93)

36–50 35.2 (69)

51–65 17.8 (35)

Certification

Primary care paramedic 85.3 (168)

Advanced care paramedic 14.7 (29)

Years employed

0–9.9 years 46.5 (92)

10.0–19 years 27.0 (53)

20–29 years 16.2 (32)

30 + years 10.3 (20)

Employment status

Full-time 70.7 (139)

Part-time/Casual/Modified duty 29.3 (58)

LHIN geographical area

Northeast 65.4 (129)

Northwest 34.6 (68)

Work location

Rural 54.4 (107)

Urban 45.6 (90)

CP experience

Yes 43.7 (86)

No 56.3 (111)

Sick days/year

None 28.9 (57)

1 to 5 42.1 (83)

6 to 10 15.7 (31)

11 to 15 3.6 (7)

Over 15 9.7 (19)

Self-rated mental health

Good/Excellent 40.1 (79)

Self-rated physical health

Good/Excellent 47.7 (94)

Category	% Total (n = 197)
Sex
Male	71.6 (140)
Female	28.4 (57)
Age
20–35	47.0 (93)
36–50	35.2 (69)
51–65	17.8 (35)
Certification
Primary care paramedic	85.3 (168)
Advanced care paramedic	14.7 (29)
Years employed
0–9.9 years	46.5 (92)
10.0–19 years	27.0 (53)
20–29 years	16.2 (32)
30 + years	10.3 (20)
Employment status
Full-time	70.7 (139)
Part-time/Casual/Modified duty	29.3 (58)
LHIN geographical area
Northeast	65.4 (129)
Northwest	34.6 (68)
Work location
Rural	54.4 (107)
Urban	45.6 (90)
CP experience
Yes	43.7 (86)
No	56.3 (111)
Sick days/year
None	28.9 (57)
1 to 5	42.1 (83)
6 to 10	15.7 (31)
11 to 15	3.6 (7)
Over 15	9.7 (19)
Self-rated mental health
Good/Excellent	40.1 (79)
Self-rated physical health
Good/Excellent	47.7 (94)

There were 168 (85.3%) primary care paramedics and 14.7% (n = 29) advanced care paramedics who completed the survey. The majority of the paramedics worked in rural locations with 54.4% (n = 107), and in northeast Ontario there were 65.4% (n = 129) paramedics. In addition, in terms of self-reported mental health, 17.7% (n = 35) of paramedics indicated poor/very poor mental health and 40.1% (n = 79) indicated good/excellent mental health.

3.1 Overall paramedic QoWL results

The mean subscale scores and overall QoWL scores are portrayed in Table 2 with descriptive category referencing scale norms. Normality assumptions were met using the Shapiro-Wilk test. Co-linearity testing for independent variables was conducted using variance inflation factors. The overall mean QoWL score was 73.99 based on 197 responses, and this was considered average compared to United Kingdom National Health Service scale norms (scale minimum = 15; scale maximum 115).

Table 2
23-Item WRQoL scale and sub-scale paramedic means

Subscale Mean score (norm category) Norm ranges Standard deviation

GWB 21.62 (Average) 6–30 4.38

HWI 8.52 (Lower) 3–15 2.45

JCS 19.45 (Lower) 6–36 3.87

CAW 8.80 (Lower) 3–15 2.89

WCS 9.89 (Lower) 3–15 2.52

SAW 5.39 (Average) 2–10 1.96

Overall QoWL 73.99 (Average) 1–115 12.94

Subscale	Mean score (norm category)	Norm ranges	Standard deviation
GWB	21.62 (Average)	6–30	4.38
HWI	8.52 (Lower)	3–15	2.45
JCS	19.45 (Lower)	6–36	3.87
CAW	8.80 (Lower)	3–15	2.89
WCS	9.89 (Lower)	3–15	2.52
SAW	5.39 (Average)	2–10	1.96
Overall QoWL	73.99 (Average)	1–115	12.94

Categories: In reference to UK National Health Service norms.

A statistically significant linear regression model was observed with the QoWL scale (R² = 0.183, p < 0.001). Self-perceived mental health (b = 0.145, p = 0.002), number of sick days per year (b = –0.137, p < 0.001), and participation in a community paramedicine program (b = 0.180, p = 0.048) were statistically significantly associated with improved QoWL.

3.2 Paramedic sub-scale results

Statistically significant linear regression models were also observed with the general well- being sub-scale (R² = 0.139, p = 0.01), job-career satisfaction sub-scale (R² = 0.145, p = 0.01), working conditions sub-scale (R² = 0.163, p < 0.001). The SAW (R² = 0.115, p = 0.07) and CAW (R² = 0.086, p < 0.10) were also statistically significant linear regression models.

The results of the multiple linear regression analyses appear in Table 3. Paramedic sex was a statistically significant predictor for the job-career satisfaction subscale (b = 0.245, p = 0.016); female paramedics were shown to have higher job/career satisfaction scores than male paramedics in northern Ontario. Self-perceived mental health was a statistically significant predictor of general well-being (b = 0.161, p = 0.008), working conditions (b = 0.140, p = 0.004), stress at work (b = 0.205, p = 0.013), and control at work (b = 0.198, p = 0.086). Years employed as a paramedic was a significant predictor of stress at work; fewer years employed as a paramedic was associated with higher stress at work scores (b = –0.018, p = 0.013).

Table 3
Independent multiple linear regression results for paramedic QoWL and subscales

Overall QoWL β (std. error) GWB β (std. error) HWI β (std. error) JCS β (std. error) CAW β (std. error) WCS β (std. error) SAW β (std. error)

Independent model R² 0.183 ^* 0.139 ^* 0.067 0.145 ^*** 0.086 ^* 0.163 ^* 0.115 ^

Personal factors Sex 0.102 (0.089) 0.087 (0.114) 0.071 (0.133) 0.245^ (0.101) 0.119 (0.155) 0.160 (0.131) –0.069 (0.156)

Physical health –0.053 (0.053) –0.076 (0.069) –0.041 (0.080) –0.030 (0.061) –0.035 (0.093) –0.094 (0.079) –0.041 (0.094)

Mental health 0.145^* (0.046) 0.161^*** (0.060) 0.105 0.069 0.064 (0.053) 0.140^* (0.081) 0.198^* (0.068) 0.205^ (0.081)

Years employed 0.002 (0.005) –0.001 (0.006) 0.011 (0.007) 0.008 (0.005) 0.010 (0.008) 0.003 (0.007) –0.018^ (0.008)

Sick days/year –0.137^* (0.035) –0.167^* (0.045) –0.105^ (0.052) –0.142 (0.040) –0.152^ (0.061) –0.201^* (0.052) –0.056 (0.061)

Organizational factors Full-time –0.013 (0.071) –0.063 (0.091) –0.057 (0.106) 0.061 (0.081) 0.004 (0.123) 0.007 (0.104) –0.027 (0.124)

Yes CP experience 0.180^** (0.091) 0.139 (0.117) 0.215 (0.136) 0.184^* (0.103) 0.291^* (0.158) 0.085 (0.134) 0.168 (0.159)

EMS Service with CP 0.004 (0.021) 0.010 (0.026) 0.005 (0.031) 0.003 (0.023) 0.031 (0.036) –0.018 (0.030) –0.005 (0.036)

Rural 0.072 (0.086) (0.076) (0.110) –0.040 (0.129) 0.063 (0.098) –0.127 (0.395) 0.152 (0.126) 0.306^** (0.151)

		Overall QoWL β (std. error)	GWB β (std. error)	HWI β (std. error)	JCS β (std. error)	CAW β (std. error)	WCS β (std. error)	SAW β (std. error)
	Independent model R²	0.183 ^***	0.139 ^***	0.067	0.145 ^***	0.086 ^*	0.163 ^***	0.115 ^**
Personal factors	Sex	0.102 (0.089)	0.087 (0.114)	0.071 (0.133)	0.245^** (0.101)	0.119 (0.155)	0.160 (0.131)	–0.069 (0.156)
	Physical health	–0.053 (0.053)	–0.076 (0.069)	–0.041 (0.080)	–0.030 (0.061)	–0.035 (0.093)	–0.094 (0.079)	–0.041 (0.094)
	Mental health	0.145^*** (0.046)	0.161^*** (0.060)	0.105 0.069	0.064 (0.053)	0.140^* (0.081)	0.198^*** (0.068)	0.205^** (0.081)
	Years employed	0.002 (0.005)	–0.001 (0.006)	0.011 (0.007)	0.008 (0.005)	0.010 (0.008)	0.003 (0.007)	–0.018^** (0.008)
	Sick days/year	–0.137^*** (0.035)	–0.167^*** (0.045)	–0.105^** (0.052)	–0.142 (0.040)	–0.152^** (0.061)	–0.201^*** (0.052)	–0.056 (0.061)
Organizational factors	Full-time	–0.013 (0.071)	–0.063 (0.091)	–0.057 (0.106)	0.061 (0.081)	0.004 (0.123)	0.007 (0.104)	–0.027 (0.124)
	Yes CP experience	0.180^** (0.091)	0.139 (0.117)	0.215 (0.136)	0.184^* (0.103)	0.291^* (0.158)	0.085 (0.134)	0.168 (0.159)
	EMS Service with CP	0.004 (0.021)	0.010 (0.026)	0.005 (0.031)	0.003 (0.023)	0.031 (0.036)	–0.018 (0.030)	–0.005 (0.036)
	Rural	0.072 (0.086)	(0.076) (0.110)	–0.040 (0.129)	0.063 (0.098)	–0.127 (0.395)	0.152 (0.126)	0.306^** (0.151)

Note: (^*p < 0.10, ^**p < 0.05, ^***p < 0.01) B = standardized beta coefficient std. error = standard error.

Number of sick days per year was a significant predictor of lower general well-being (b = –0.167, p < 0.001), home-work interface (b = –0.105, p = 0.047), control at work (b = –0.152, p = 0.013), and working conditions (b = –0.201, p < 0.001). The results demonstrated that paramedics who had a lower number of sick days per year tended to have higher quality of work life, general well-being, work-life balance, control at work, and experienced better working conditions.

Participation in a CP program was statistically significant as a predictor of job satisfaction (b = 0.184, p = 0.076,) and control at work (b = 0.291, p = 0.067). It was also observed rural practice location was a significant predictor of stress at work (b = 0.306, p = 0.044) which indicates that rural paramedics were at a higher risk of job stress.

4 Discussion

Higher self-reported mental health, fewer sick days per year and participation in a CP program were associated with higher overall quality of work life. Interestingly, higher self-rated mental health was a statistically significant predictor of higher overall QoWL, whereas self-rated physical health was not found to be a significant predictor of QoWL or its subscales. Physical health is an essential aspect of paramedicine due to the physical demands such as lifting patients, performing CPR, operating an ambulance, shift-work, and standing/moving for long periods. Due to paramedicine’s physical nature (e.g. lifting patients), it was expected that self-rated physical health might predict overall QoWL, which was not evident in this study. Previous research has found that higher self-rated physical health was associated with higher psychological well-being [45]. An explanation of this finding may include due to lower call volumes in rural areas, physical demands may be typically lower.

The results indicated that self-reported mental health was a significant predictor of overall QoWL, and general well-being, control at work, working conditions, and stress at work sub-scale scores. Self-reported mental health is an important indicator of overall mental well- being [46], and not surprisingly, this was positively associated with QoWL for paramedics in our study. Self-reported mental health was used as a factor in this study because previous literature has demonstrated self-perceived mental health to be a good indicator of overall health [46].

Findings from this study suggest that participation in CP may positively impact QoWL. This finding is similar to previous research demonstrating that participation in a community-based program similar to CP improved job satisfaction [47]. Control at work is an important factor that mitigates job strain [19].

The JDCF Framework contains two important factors, job demand (stress) and job control. Similarly, the WRQoL scale contains stress at work and control at work subscale. The job control/CAW subscale, the number of sick days paramedics had in one year was a statistically significant predictor of job control. Regarding the stress at work subscale, self-perceived mental health, years employed, and rural work locations were statistically significant predictors of job demands. In the study’s theoretical framework, it was expected that paramedics who practiced CP would have higher control at work and less stress at work due to the low-stress environment associated with CP [19]. The results suggest that paramedics who were participating in CP demonstrated a higher overall quality of work life and job satisfaction; they were individually more able to exercise job autonomy in the workplace as indicated by the control at work subscale. The results are aligned by the theoretical model, however, the study design does not permit us to conclude that CP resulted in higher quality of work life. Nonetheless CP implementation may be a relevant operational stress mitigation strategy for on-duty paramedics in other rural contexts with lower call volumes. Future research should further explore this association since it has substantive positive implications for paramedicine and CP’s evolving practice in Ontario.

Another factor affecting operational stress and psychological well-being at work was years of service or job tenure. Job tenure has been positively correlated with improved mental health in first responders, including paramedics [48]. The results from Brough’s study demonstrated that fewer years employed predicted higher levels of stress; these findings were reflected with the higher stress at work scale scores in this study, which indicated higher stress of paramedics with lower years in service. However, other research demonstrated that job tenure is not a significant predictor of psychological well-being at work [49]. Job tenure may contribute to higher levels of psychological well-being at work, and the reason for this may be because those who work in EMS for more extended periods can develop higher levels of resilience to stressful situations [50]. Resiliency is strongly correlated with general well-being and with general health in paramedics [50]. Resiliency is likely an important psychological well-being factor since it helps a person adapt to stressful situations, which may be otherwise detrimental to a person’s physical, mental, social, and family health [51].

Previous literature demonstrated that rural paramedics experience higher occupational- related stress than their urban counterparts [17], and the finding was related to higher rates of mental health disorders [17]. There has been very little research conducted regarding rural paramedics and their mental health and well-being, however, Courtney et al. [17] found that it is lower than urban paramedics. In this study, paramedics who worked in rural areas also had higher stress at work scores, indicating they experienced higher stress at work, which is a more desirable outcome for well-being. One contributing factor to this could be the difference in call volumes between the rural and urban centres. Compared to urban paramedics, rural paramedics experience lower physical activity levels and exhibit higher levels of chronic fatigue, depression, anxiety, and stress [17]. According to Courtney et al., this can be attributed to limited education, social isolation, and lack of social support. Hamilton [14] identified other occupational stress sources experienced by rural paramedics such as forced rural posting, isolation/lack of clinical support, difficult work patterns, loss of skills, and personally knowing their patients. It is unknown from the literature how paramedic work-life balance relates to mental health 7 [17].

Employment status (part-time vs. full-time) was not a significant predictor of QoWL scale or the subscales in our study. Previous research shows that psychological well-being may differ regarding employment status (e.g. full-time and part-time employees), although the evidence is conflicting [52]. Regarding teamwork, positive climate, perceptions of management, and working conditions, part-time paramedics scored higher than full-time paramedics in these areas of psychological well-being at work [52]. In a related health profession involving shift work, there was no difference in psychological well-being between full-time and part-time in a cohort of emergency nurses [53].

Traditionally, first responder occupations such as paramedicine, police, and firefighting have been male dominant; however, there is a lack of consistency in the evidence for sex-related differences to psychological well-being at work work-related stress. Some research has demonstrated that females have higher levels of operational stress amongst first responders [54]. Haarr et al. [54] suggested that there were higher operational stress rates experienced by female first responders due to increased harassment and discrimination, over-hostility, and negative public interactions on the job. The results from this study indicated sex to be a significant predictor of job/career satisfaction sub-scale; female paramedics had higher scores for job satisfaction. Additional research is required to further investigate this association.

Another significant predictor variable in our study, the number of sick days that a paramedic was away from work, was negatively associated with general well-being, home-work interface, control at work and working conditions scales. Intuitively this finding is not surprising, given that sickness would be expected to lead to lower QoWL. It has been reported that health workers on shift-work experience more sick days per year and have a lower health status compared to those who work regular day hours [55]. Burch et al. [55] reported that this is likely due to a lifestyle change that impacts sleep, time spent with family, and hobbies. Although shift work was not a variable in our study, it may be a mediating variable that helps explain why higher reported sick days were associated with lower QoWL when compared to other non-emergency occupations.

There were several subscales such as home-work interface, job/career satisfaction, control at work and working conditions where paramedics scored lower than average compared to the reference group as detailed by Easton and Van Laar [29]. The reference group was from the United Kingdom National Health Service employees who were employed at United Kingdom hospitals and primary care centres. In other words, this suggests that many of the paramedics in our study had lower than average work-life relationships, job/career satisfaction, control at work, and perceived working conditions compared to this reference group. According to Easton and Van Laar [29], these lower scores could be detrimental to their overall health. Regarding working conditions and control at work, the theoretical framework (JCDF) for this study outlined that employees with little control at work experience adverse health effects due to the lack of inability to make their own decisions [19]. Lower job satisfaction and working condition scores could be related to detrimental physical and mental health effects [19].

The scales that scored in the average reference category were general well-being, stress at work, and overall QoWL. Easton and Van Laar [29] suggest that those employees who score in the average category do not receive positive benefits nor negative benefits from their work; however, positive workplace changes are still needed to be made to improve their QoWL. It is important to note that paramedics often planned and implemented CP activities, and this may be the aspect of job control that helps explain the higher QoWL experienced by the paramedics practicing CP in our study. It is also important to note that some CP programs in northern Ontario are unique compared to other CP programs because many of these rural paramedics practice CP in addition to their regular emergency response duties when they are between emergency calls [2]. This is feasible due to lower call volumes; this rural practice was the context for over half of the respondents in our study (54.4%). In urban areas with higher call volume, other paramedic services have dedicated paramedics performing only CP duties. Regehr and Millar [12] found that paramedics practicing in this type of urban context had high job demand and low job control.

The findings related to the association between higher QoWL for those paramedics practicing CP suggest that the JDCF may relate to paramedic overall QoWL because it helps explain how work-related stress may be alleviated if paramedics have higher control in their daily duties and more opportunities to engage in their decision-making which would lead to a more active job. Practicing CP presents paramedics opportunities to utilize their decision-making capabilities to a higher degree since they are not following specific guidelines outlined in the Ambulance Act, 1990 R.S.0.1990, c. A.19. While performing CP duties, paramedics decide which health promotion and/or clinical duties they feel are necessary, such as blood pressure measuring, medication reconciliation, or providing lifestyle advice.

CP may impact overall QoWL of paramedics who experience lower call volumes since this increases job demands but also increases job control leading to a more desirable work environment [19]. The JDCF also suggests that employees who have high job demands and low control experience a higher job strain, and this has negative health effects [19]. Since paramedics not practicing CP respond only to medical emergencies, they are exposed to high-stress environments such as death of children, medical emergencies (cardiac arrests), severe motor vehicle collisions, acts of violence, suicide, organizational issues, lack of job autonomy, physical strain, and lack of supervisor support [51]. Typically, call volumes at EMS bases in northern Ontario are lower compared to those in Southern Ontario. EMS providers who have CP programs may be providing a more active and diverse job role in which paramedics provide proactive health education and other health promotion advice for patients in an environment that may be less stressful than a medical emergency. It also provides an environment where paramedics can exercise greater job autonomy since they can practice other skills, such as providing medication reconciliation advice and treating patients in a medical emergency.

4.1 Implications

Measuring QoWL is vital since it provides a measure of an employee’s well-being from their workplace experiences. In Canada, the economic cost of mental illness is approximately 51 billion dollars, and it is the leading cause of disability in Canada [57]. Thus, it is likely that these costs can be reduced if more efforts are focused on preventing workplace mental illness. From an organizational standpoint, leaders and managers should ensure the workplace does not have detrimental psychological effects on their employees [29]. Our study’s findings are important for EMS providers to design and invest in workplace wellness programs that may improve the QoWL of paramedics and generate cost savings related to the prevention of mental illness.

The findings from this study provided some insight into the working lives of paramedics practicing across northern Ontario. This is valuable information that can be used by EMS management to gain insight into their employees’ perceived QoWL. They can use this information to design, implement, or improve workplace wellness programs to enhance paramdic QoWL and perhaps reduce the workforce’s number of sick days. These initiatives could include improving employee assistance programs, enhancing medical benefits, implementing health and wellness programs, and initiating stress reduction programs. There is also a possibility to include more stress management wellness-related curriculum in paramedic college training programs. Workplaces need to offer health and wellness initiatives/supports to address the impact of both critical incident stress and chronic occupational stress [58].

Another important implication of this study is that it is one of the first studies to compare QoWL of paramedics who have participated in a CP program with paramedics who have not participated in a CP program. CP is still a relatively new program in Ontario, and with that comes a compelling need to understand how it is received and perceived by frontline paramedics. The results from our study indicated that there might be a correlation with paramedics who participated in CP and higher QoWL. Though this is not a causal relationship, it is undoubtedly very suggestive that the paramedics positively receive CP from northern Ontario. Interestingly, practicing CP may improve the health and well-being of paramedics and that of the patients that the CP program was designed to help. This information is vital for EMS providers and the administrative bodies responsible for CP operations to aid in decision-making related to the provision of future services, expansion, and sustainability.

5 Limitations

There are a few limitations when interpreting the results of our study. As a cross-sectional study, we can only describe associations between variables, but not test causality. Also, the independent regression models were only able to explain a certain degree of the variance in QoWL and its subscales. Thus, there were likely other important factors related to QoWL that were not considered in this study. However, this exploratory study was designed to identify associations between QoWL and several personal and organizational factors. The QoWL scale used in this study was a holistic measure of workers’ well-being through several constructs (general well-being, home-work interface, job-career satisfaction, control at work, working conditions, and stress at work). Several psychological constructs could be used to predict relationships with well-being and work-related factors, several of the predictor variables demonstrated statistically significant effects with QoWL and its subscales. Thus, future studies with similar designs are required to explore these and other factors, in order to understand paramedic QoWL better. Finally, even though we use the term “predictor variable” to describe the independent variables, the research design was not causal, and thus, the Working Condition sub-scale may not be a relevant dependent variable in the model given the nature of several other predictor variables such as General and Mental Health.

Many well-being constructs can be measured with employees and only specific aspects were measured in this study with the QoWL scale used. For example, other aspects of well-being that were not specifically measured in the WRQoL scale that could have been measured were: poor communication, insufficient salaries, lack of social support, physical strains, intent to leave, attrition, and resilience [50].

The survey was only made available via a web-based link, and this may not have been the desired mode of completion for some of the participants, which may have contributed to a lower response rate. Two issues that may arise from using web-based surveys are poor internet service and spam fear [59]. Due to the rural location of many of the EMS bases, poor internet service could have been a possibility for some paramedics, and this may have prevented them from participating.

Additionally, it is essential to note response bias’s potential due to the sample’s personality types. Past research has demonstrated that those who possess higher emotional stability are more likely to complete web-based questionnaires than those with lower emotional stability [59, 60]. Therefore, it is possible that the paramedics who fully responded to the online survey could have possessed a higher QoWL compared to those paramedics who did not complete the survey.

It is also important to note that CP was a relatively new program at the time of survey distribution, where paramedics may have had little experience practicing CP at the time. If this study was to be replicated several years in the future, the CP-related QoWL results could be compared to the results presented in our study.

6 Conclusion

This study has demonstrated that the QoWL, general well-being, and stress at work of paramedics practicing in northern Ontario is average compared to established norms from a sample of health professionals in the United Kingdom. This study’s findings also demonstrated that paramedics in this northern Ontario sample experience low home-work interface, job/career satisfaction, control at work, and working conditions. In addition, this study has highlighted some of the personal and organizational factors that affect QoWL. One of the striking findings in this study in the association between CP and better QoWL. Further research to further illuminate the relationship between of CP on QoWL may illuminate whether CP actually contributes to improved QoWL for paramedics, in this or other jurisdictions across Ontario. Additionally, ensuring paramedic employers are aware of the personal and organizational factors that affect QoWL, may be an initial step in helping to mitigate occupational stress.

Improving working conditions and ensuring employers provide their paramedics with adequate resources for mental health support are important. There may be a need to implement additional or enhanced workplace mental health support initiatives to help improve paramedics’ psychological well-being. This is the first study to examine paramedic QoWL in northern Ontario to the best of our knowledge. Further research is needed to understand better QoWL and the association between QoWL and CP in other paramedic populations in Ontario and beyond.

Conflict of interest

None to report.

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