BY LAURA HIRELLO AND CHERYL CAMERON
What is social accountability?
Over the past few decades, health and medical researchers have begun to recognize the role external factors play in an individual’s health. These factors, now called the determinants of health (DOH), include cultural and societal structures like living conditions, income, birthplace as well as personal attributes including race, gender, and ability. (1,2. The impact the DOH have on individual and population health has led global organizations to call on healthcare providers to address social issues and inequitable care as part of their practice. (3–5) As healthcare shifts its focus from disease-specific treatment to person-centered care, providers must ensure they are addressing the root causes that lead to poor health resources.
Paramedicine has evolved into a healthcare profession that provides high quality mobilized care in community settings across the country. The healthcare sector is beginning to recognize the ability paramedics have in the provision of healthcare to any community, regardless of time of day, environment, or other accessibility challenges. The network of care created by paramedics provides an essential opportunity to bring healthcare to isolated and vulnerable communities. (6–8) However, this role can only be achieved if the paramedic profession works collectively to prioritize socially accountable practice. (4) The principles of social accountability strengthen the profession’s duty to provide equitable, culturally competent care to patients and families in all environments, regardless of race, gender, ethnicity, social status, or any other demographic. Paramedicine has a key role to play in ensuring healthcare in Canada is safe, appropriate, and accessible for all who need it. Ensuring all paramedics practice in a socially accountable, patient centric way is an essential step toward fulfilling this role.
Enacting Social Accountability in Paramedicine
In developing a socially accountable profession, the focus of paramedicine must shift from reactionary response to proactive anticipation of needs. (9) Community involvement is critical to identifying needs, setting priorities, establishing and evaluating new models of care. (10) Through engagement with the community, paramedicine can evolve in a patient-centered manner and ensure that social accountability is embedded into all its operations.
A socially accountable paramedic practice anticipates social needs, incorporates societal feedback in creating service objectives, contextualizes education based on identified needs, ensures graduates are of high quality and focuses on patient impact when evaluating new models of care. (11) This type of shift requires unified national strategies that align the priorities of the paramedic profession with the rest of healthcare. One of the clear barriers to the establishment of socially accountable practices in paramedicine is the lack of a cohesive governing body, or accreditation program. While national level paramedic groups do exist, they have no direct governance capacity over local paramedicine operations. They lack the national infrastructure to hold services accountable to profession-level strategies and standards. (12) Other medical professions have consistent regulatory standards across provinces that enact and enforce standards for socially accountable care. (13) These principles are further strengthened by their valuation in accreditation programs. (14) As outside agencies, national accreditation organizations reflect the current standards of practice and expectations of care across all types of healthcare. Accreditation bodies act as an external pressure for the adoption of both socially accountable clinical practices and organizational policies. (14) They also generally function at a national level, allowing for uniformly enforced socially accountable practices across provinces. Accreditation standards are a key lever for embedding social accountability into paramedic services. (14)
All provincial and national paramedic organizations (regulators, associations) must have clearly communicated values around social accountability. The mission and vision of the Paramedic Association of Canada, for example, is to ‘provide quality care for the public through leadership in the advancement of the profession of paramedicine.’ (15) In fulfillment of this vision, the PAC, and other groups are obliged to champion the calls to action that currently exist in Canada around decreasing health disparities for marginalized populations. For example, the Truth and Reconciliation Commission (16) published several “calls to action” directed at healthcare such as addressing the distinct health needs of the Métis, Inuit, and off-reserve Aboriginal peoples, establishing measurable goals to identify and close the gaps in health outcomes between Aboriginal and non-Aboriginal communities, and to publish annual progress reports and assess long-term trends. These are clearly identified social accountability goals that all paramedic services can adopt.
Educational programs and schools have a duty to respond to the changing landscape of paramedicine to ensure students are fit to practice. In order to appropriately prepare paramedic students, educators must be aware of the evolving needs of the community to develop formal mechanisms for responding to, and advocating for, these mandates. (17) A lack of specific focus and training on socially accountable care practices can lead to negative provider attitudes. (18) Implicit biases and prejudice of healthcare providers has been shown to affect the quality and treatment decisions of care. (19–21) These prejudices are regrettably common, with the media reporting multiple examples of Canadian provider bias in 2020 alone. (22–24) Paramedic students already demonstrate provider bias in empathy levels. (25) Paramedic students, like everyone in society, possess their own prejudices and biases. Without specific attention or training during their paramedic education, these attitudes will continue through a paramedic’s career. (26)
Paramedic academic institutions must develop curricula that prioritizes education about DOH, equity-oriented care models and collaboration with local community groups. (27) Paramedic educators, preceptors and mentors should model socially accountable practice, and paramedic research and clinical experiences should also be used to advocate for social programming and change. The TRC calls upon all institutions educating health professionals to develop cultural competency around indigenous health issues, including training about the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices. (16)
In addition, paramedic educational programs must ensure they are recruiting and supporting diverse student cohorts. As educational programs are the starting point for all paramedics, it is essential that schools eliminate barriers that lead to inequity of the gender, race, ethnicity, or social status of individuals entering the profession. (28)
The valuation of social accountability must also be present in the paramedic workforce. Investments into paramedic workforce diversity that focus on ensuring employees are representative of the populations they are servicing helps facilitate culturally literate practice and is through the introduction of new perspectives. (29) Workforces that are representative of the community are essential for establishing trust and connections with organizations and groups within that community. (29) The TRC specifically identifies increasing the number of Aboriginal professionals working in the health-care field and ensuring the retention of Aboriginal health-care providers in Aboriginal communities as key calls to action for those delivering health services. In addition, employers are called to provide cultural competency training for all health-care professionals. (16) Workforce diversity at all levels helps drive paramedic professional discourse and build social accountability through the continued exposure to different perspectives, norms, and customs. (29)
Paramedic services and organizations should provide evidence-based care and examine new models of care that account for the DOH. This work must be done in collaboration with affiliated healthcare organizations, the community, other professional groups, policy makers and governments to develop a shared vision of an evolving and sustainable healthcare system for the future. (30) Shifting the profession towards socially accountable practice requires changes at all levels. Paramedic educators must include the DOH and social accountability as part of the curricula. Paramedic clinical guidelines and standards need to address all not just acute illness, but the DOH, for all patients in an inclusive manner. (3,30) Paramedic educators and services must develop programs to recruit and support a more diverse workforce. Paramedic services and researchers should be mindful of the DOH and include an equity lens in their analysis and evaluation of innovations and new initiatives. Socially accountable practice must be embedded into all areas of the profession to help drive paramedicine forward. (30)
So what can the frontline paramedic do?
To effectively address social accountability in paramedicine, individual paramedics must recognize their role and responsibilities. The same way all healthcare providers are responsible for safely and competently practicing within their scope, every paramedic has an individual responsibility to work towards socially accountable care. This individual responsibility starts with peer-to-peer paramedic education. It is the responsibility of all paramedics to ensure that the workplace is a safe and healthy space for everyone. The onus is on us to ensure we are educated and aware of how to respectfully interact with co-workers. This education includes self-reflection of our own biases and beliefs and making sure we have the appropriate language for talking about these issues. Paramedics need to become comfortable having open discussions about the DOH, what inequity looks like, and how best to address issues in real time. An essential part of this work involves engaging in reflection on one’s own knowledge and competency and creating spaces where we can safely engage and challenge peers and co-workers about their own pre-established ideas and biases.
At the clinical level, paramedics must incorporate questions about the DOH and social challenges into patient histories. (31) Any pertinent findings from these questions should be included in documentation and communicated during care transitions. Paramedics with a strong working knowledge of the social services and programs available in their area can provide superior care through connecting patients with these services. Knowledge of local services allows paramedics to recommend patients for referral to social programs, helping bridge gaps in a patient’s basic needs. (31)
Paramedics play an important role in the Canadian healthcare system. They deliver high quality care on demand, in any region, to whomever needs it. However, for paramedics to fulfill their potential in modern healthcare, the profession must ensure its values are aligned with all other healthcare providers. This requires enactment of socially accountable practice at all levels of the paramedic profession, including educators, employers, policy makers, other healthcare providers and most importantly, practicing paramedics.
- Solar O, Irwin A. A Conceptual framework for action on the social determinants of health [Internet]. Social Determinants of Health Discussion Paper 2 (Policy and Practice). 2010. Available from: https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf
- Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts [Internet]. Toronto; 2010 [cited 2019 Sep 15]. Available from: http://www.thecanadianfacts.org/
- Boelen C. Building a socially accountable health professions school: Towards unity for health. Educ Heal. 2004;17(2):223–31.
- Boelen C, Heck JE. Defining and measuring the social accountability of medical schools. Geneva, Switzerland; 1995.
- Romanow RJ. Commission on the future of health care in Canada. Building on values: the future of health care in Canada. 2002.
- Hay D, Varga-toth J, Hines E. Frontline Health Care in Canada: Innovations in Delivering Services to Vulnerable Populations. Ottawa, Canada; 2006.
- Kenny A, Hyett N, Sawtell J, Dickson-Swift V, Farmer J, O’Meara P. Community participation in rural health: A scoping review [Internet]. Vol. 13, BMC Health Services Research. BioMed Central; 2013 [cited 2020 Nov 26]. p. 64. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-13-64
- O’Meara P, Stirling C, Ruest M, Martin A. Community paramedicine model of care: An observational, ethnographic case study. BMC Health Serv Res [Internet]. 2016;16(1):1–11. Available from: http://dx.doi.org/10.1186/s12913-016-1282-0
- Eraut M. Developing Professional Knowledge And Competence. Developing Professional Knowledge And Competence. Routledge; 2002.
- Browne AJ, Varcoe CM, Wong ST, Smye VL, Lavoie J, Littlejohn D, et al. Closing the health equity gap: Evidence-based strategies for primary health care organizations. Int J Equity Health. 2012;11(59).
- Boelen C, Dharamsi S, Gibbs T. The social accountability of medical schools and its indicators. Educ Heal Chang Learn Pract. 2012;25(3):180–94.
- Symons P, Shuster M. International EMS systems: Canada. Resuscitation. 2004;63(2):119–22.
- Williams B, Fielder C, Strong G, Acker J, Thompson S. Are paramedic students ready to be professional? An international comparison study. Int Emerg Nurs [Internet]. 2015;23(2):120–6. Available from: http://dx.doi.org/10.1016/j.ienj.2014.07.004
- Boelen C, Woollard B. Social accountability and accreditation: a new frontier for educational institutions. Med Educ. 2009;43:887–94.
- Paramedic Association of Canada. Paramedic Association of Canada 2018-2020 Strategic Plan [Internet]. 2018 [cited 2021 Mar 27]. Available from: www.paramedic.ca
- The Truth and Reconciliation Commission of Canada. Honouring the Truth, Reconciling for the Future [Internet]. Ottawa, Canada; 2015 [cited 2020 Nov 27]. Available from: www.trc.ca
- Boelen C, Pearson D, Kaufman A, Rourke J, Woollard R, Marsh DC, et al. Producing a socially accountable medical school: AMEE Guide No. 109. Med Teach. 2016;38(11):1078–91.
- Masson N, Lester H. The attitudes of medical students towards homeless people: Does medical school make a difference? Med Educ. 2003;37(10):869–72.
- Branicki LJ. COVID-19, ethics of care and feminist crisis management. Gender, Work Organ. 2020;27(5):872–83.
- Institute of Medicine. Unequal Treatment: Confronting racial and ethnic disparities in health care. Washington, DC; 2003.
- Sabin JA, Rivara FP, Greenwald AG. Physician Implicit Attitute and Stereotypes about Race and Quality of Medical Care. Acad Manag Rev. 2006;31(2):386–408.
- Morin B. Indigenous Women Face Abuse, Racism In Childbirth [Internet]. Refinery 29. 2020 [cited 2020 Nov 27]. Available from: https://www.refinery29.com/en-ca/2020/11/10118532/indigenous-women-abuse-childbirth-hospitals
- Rowe DJ. Investigation underway after family says Indigenous man died in Quebec hospital after overhearing racist remarks [Internet]. CTV News. 2020 [cited 2020 Nov 27]. Available from: https://montreal.ctvnews.ca/investigation-underway-after-family-says-indigenous-man-died-in-quebec-hospital-after-overhearing-racist-remarks-1.5146291
- Shingler B, Page J, Leavitt S. Racism at Quebec hospital reported long before troubling death of Atikamekw woman [Internet]. CBC News. 2020 [cited 2020 Nov 27]. Available from: https://www.cbc.ca/news/canada/montreal/quebec-joliette-hospital-joyce-echaquan-1.5745150
- Pagano A, Robinson K, Ricketts C, Cundy-Jones J, Henderson L, Cartwright W, et al. Empathy Levels in Canadian Paramedic Students: A Longitudinal Study. Irish J Paramed. 2018;3(2):1492–9.
- Van Ryn M, Hardeman R, Phelan SM, Burgess Phd DJ, Dovidio JF, Herrin J, et al. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report. J Gen Intern Med. 2015;30(12):1748–56.
- Essington T, Bowles R, Donelon B. The Canadian Paramedicine Education Guidance Document. 2018.
- Health Canada. Social Accountability: A Vision for Canadian Medical Schools [Internet]. Health Canada. Ottawa, Canada; 2001. Available from: http://www.iime.org/documents/hawkins.htm
- Wilbur K, Snyder C, Essary AC, Reddy S, Will KK, Mary Saxon. Developing Workforce Diversity in the Health Professions: A Social Justice Perspective. Heal Prof Educ [Internet]. 2020 Jun [cited 2021 Mar 27];6(2):222–9. Available from: www.sciencedirect.comwww.elsevier.com/locate/hpe
- Allana A, Pinto A. Paramedics Have Untapped Potential to Address Social Determinants of Health in Canada. Healthc Policy | Polit Santé. 2021 Feb 22;16(3):67–75.
- Andermann A. Taking action on the social determinants of health in clinical practice: A framework for health professionals. Cmaj. 2016;188(17–18):E474–83.