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Implications of Power, Position, and Privilege in Paramedic Practice

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By Becky Donelon

How we understand our own identity and competence in relation to what the patient needs or wants influences how we provide good care in our practice. We provide care to many different populations in many diverse settings address(ing) gaps in an evolving and stressed healthcare system  that cross boundaries and factors of gender, geography, sex, socioeconomic status, age, and disability. Better understanding of how these factors implicate how we view and care for patient populations is emerging. Our ability to incorporate relevant research, and the development of evidence based practice to meet the individual patient need, needs to reflect the differences (where they matter) across not only boundaries of biology, but the context in which people experience the world. Such as how sex determines response to illicit drugs or susceptibility to disease, where males and females are proven to respond different. Or how gendered experiences between paramedic students and preceptors influence learning during practicum placements . Where sex and gender are often thought to be interchangeable, they are not, one is a social construct with cultural meanings, and one is a biological difference that can matter.

It can be difficult to challenge our own thinking in practice, to question our assumptions and perceptions of the patient presentation and context of the event during the call, it is much easier to rely on our stereotypes and tropes to direct how and if the patient will receive our care. Similarly, it is easy to accept the evidence (assumed to be representative) in medical protocols without question until we are presented with the atypical gender presentation. If we can think critically about the evidence underpinning our practice and our own presumptions and assumptions about what we are being presented with by the patient, we can improve our practice. Understanding and utilizing the lens of intersectionality enables an appreciation for the complexity of power, social location, and privilege to enter into our critical thinking and actions of daily practice.

Paramedics are like other health professionals who are intentional beings with intersecting identities practicing in settings of hierarchies related to power, gender, sexualities, and social relations . Knowing this and knowing the ability we have to influence patient centered care is the opportunity to be intentional about our act(s) of caring. The provision of health care is a social interaction, we operate in the human domain out in the environment and context of and with our patient. To access our patient, we must step into their social space and location in order to interpret the scene. However, it is the paramedic who often holds disproportionate power in the event. The language we chose to use if the patient is conscious influences how the patient will respond to our questions and directions, or how the receiving health practitioner hears the “story” about mechanism of injury (from our view) for the patient with altered consciousness. In this paramedic – patient relationship, every little action and word cause the experience of providing care and receiving care to occur in a particular way. In this way we act, often unknowingly, based on our own intersections of gender, race, power, and privilege.

Consider that each patient encounter we have is dependent on the social agreement that underpins our entire practice, without the relationship with each of our work partners, and the patient, we would not have an event in which we could provide care. It is paramedicine’s core function as responding to the patient’s side in an emergency to provide urgent care  that puts us into this context. In each of these interactions’ paramedics bring assumptions and in some cases stereotyping, racism, incompetence, and fear of other, alongside assessment of the scene and what we chose to see of the patient presentation. In many cases these are positive aspects of our practice knowledge that help us to quickly determine the best next step for the patient. However, our assumptions and understanding of norms is directly linked to our own social location and we can be at risk for less than relevant care when not vigilant in awareness of our own bias and power.

Across Canada, many people experience health inequity. Within the notion of intersectionality, inequity is never the result of a single or distinct factor but are an outcome of the intersection of multiple social locations, complex power relations and experiences. Emerging paramedicine scholarship provides better understanding for us in areas of social determinants of health and the implications of this on our practice. Without question, we know that many of the patients we encounter have inadequate access to necessities, such as water, food, and shelter. World Health Organization defines social determinants of health as the conditions in which people are born, grow, live, and age and the inequality some experience due to their social location is a foundational factor to their health , and eventually, when we interact with these patients, to our practice.

An obvious example of health inequity we often encounter are the people who are considered homeless. Regardless of practice setting, every paramedic will eventually engage with someone who lives according to a different norm, such as on the street or in the rough. If we consider how our social location drives the entire interaction we have with this patient, we can disrupt the status quo and reduce recidivism. The person living in a homeless shelter at night and moving in public spaces during the day presents us with a number of intersections across gender, age, race, and disability that influence how they respond to us and how we perceive their presentation of health care needs. Health inequities are defined as differences in health outcomes that are deemed unfair, avoidable, or changeable. This means that when a patient or subset population experiences more illness due to poverty, discrimination, or lack of access, it is health inequity. Consider the intersectionality of Indigenous women, who while they make up just over 4% of total Canadian women are four times more likely to be murdered than a Caucasian woman . Its unknown how often indigenous women who are murdered were categorised as homeless, but we must consider this type of connection, how race, gender, socioeconomic status contributes, and how it may change what actions we take when next developing a treatment plan for the homeless Indigenous woman we encounter on a Thursday night.

Intersectionality influences how we bring ourselves to work each day and interact with our work partners. There is still considered a gendered uniqueness to all female paramedic crews such as recent public acknowledgement of an all female air medical crew. This notion that gender, a social construct, needs to be identified is an interesting aspect of norm identification. When all female crews are identified as other than the norm, in the case of paramedicine the assumption is then that most crews are male. It follows then that women must deal with the intersection of gender in a different way than men might, or different than what someone who chooses to identify as non-binary, not male or female. This intersection across gender sets up a distinction or delineation that enables power and privilege according to gender in our profession of paramedicine.

As paramedics we present at our worksites with our work teams in particular ways, including how we are viewed by other practitioners. That there is a hierarchy to our social location is apparent from our first experiences as students. Navigating the real and perceived constructions and position of power is something we learn early as paramedic students. We know this because we have all been described by a preceptor as the “newby”, “rookie” or “this is my student” instead of introduced by name, this language describes well the social location of the preceptor group who hold disproportional power and dominate the learning space over the student. How we practice is shaped by how we understand our own identity, which is directly influenced by the power dynamics of the student – preceptor relationship and how we see ourselves within these structures of relationships when learning to practice.

We need to understand intersectionality as our acknowledgement that each person is affected by existing systems of power, privilege, and oppression differently, based on the intersection of their identity factors, social status and lived experience. This recognition and application help us to understand the needs of our patient better, and how we can act to meet those needs. Intersectionality promotes understanding how people are shaped by the interaction of different social locations such as race or ethnicity, indigeneity, gender, class, sexuality, geography, age, ability, migration status, and religion. The lens of intersectionality prevents us from reducing the conversation about good care and excellent paramedic practice to singular issues such as compliance with clinical protocols that ignore the complexity of the social interactions and interdependent forms of privilege and oppression shaped by colonialism, imperialism, racism, homophobia, ableism, and patriarchy.

What each of us can consider when we evaluate how we act in our practise can be as simple as recognizing how the aspects of intersectionality may impact each of our lives, as paramedics and within our interactions with our patient. Consider how our narrative may change if we apply this lens to how we tell our story of the last call. The call we completed with frustration as a paramedic taught to save lives or focus on technical aspects of running a well organized code only to be stuck with the repeat local homeless man who just keeps calling us for “back pain” and a trip to emergency for a cheese sandwich and clean bed for a while. We often narrate this significant aspect of practice as not worthy of our time and purpose and in doing so entrench the discrimination of intersections of race, gender, age, and socioeconomic factors into our practice. Deconstructing this entrenchment found in our practice becomes possible only when we apply a critical lens to our internal dialogue about why we see this type of call in this way, and question why our story doesn’t place value in the difference we can make in this patient’s experience of health care.

Intersectionality is one way to attend to the issue of professionalism in paramedicine, in that it is a basis for understanding the power and privilege that happens in the provision of health care. That gender bias, racism and discrimination occurs in and across emergency medical services is a problem for the profession of paramedicine to address and solve in a meaningful way, not only for the patient but for the profession. As professionals in paramedicine we are best positioned to help ourselves and thereby patients who ask for our help by understanding the implications of the factors of intersectionality in every aspect of our practice. 

References

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  4. Bowles, R., vanBeek, C., Anderson, G. (2017). Four dimensions of paramedic practice in Canada: Defining and describing the profession. Australasian Journal of Paramedicine: 2017;14(3)
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Becky Donelon

Becky Donelon

Becky has worked as a paramedic in Alberta since 1981. She is proud of her roots in rural Alberta as a primary care paramedic and volunteer firefighter. Graduating in 1997 as an Advanced Care Paramedic, working in urban settings within fixed wing and ground ambulance, progressing from clinician to field supervisor to clinical educator. Becky's interest and education in paramedicine has focused on teaching, learning, and evaluation theory, achieving a Doctor of Education from the University of Calgary. Returning to paramedic education pursuits after many years in the field of paramedicine regulation, she is focused on quality paramedic education and research. Currently her work includes developing better understanding of paramedic practice education, continuing to explore the relational spaces and places of learning, and how this shapes paramedic’s ways of knowing and being.

Women in Paramedicine

Women in Paramedicine

Women in Paramedicine is compromised of dozens of women in the paramedical field across Canada. Since 2019, they have been sharing their research, point of view, thoughts, and strength to Canadian Paramedicine through their voice and words.

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