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In 2016, author Glennon Doyle narrated a short film that illustrated how centuries old building techniques were used to sustain the strong supports that hold up greater structures after – or before – they have become weakened by heavy loads. The carpenter must connect a board to the left and right to strengthen the joist so it can continue to manage the load, together. 

The term for this is Sistering. (1) 

Women in Paramedicine

While women tend to make up a larger portion of frontline health care workers (2), paramedicine started from and exists today as a strongly male-dominated profession. (3) For context, 83% of the total non-management workforce in Alberta Health Services (AHS) are women, and 71% of management are women. In Alberta Health Services Emergency Medical Services (AHS EMS), 47% of the non-management workforce are women, and women represent 21% of the management workforce. Although the number of women in AHS EMS in have increased since 2019 (up from 44% and 19% respectively), there are still significantly less women in the EMS workforce than the greater AHS organization. (4)

Paramedicine’s organizational structure remains rooted in a paramilitary command style that comes from its military roots, fire department (and first responder) upbringing, and historically male-dominated frontline and leadership. Because of this, the culture often struggles with a societal perception problem despite recent gains in equality, equity, and the influences of increased parity of genders. It is common now to have female-female partnerships in EMS, but it is still just as common for these same teams to hear comments from patients or bystanders like “you’re going to need to get some men to help” or “which one of you drives the big ambulance”. The reasons for the pay disparity warrant increased study, inspire debate, and stimulate more questions. Does the ratio reflect a natural progression of experience in the industry and therefore reflect proportions of frontline gender ratios 15 years ago? Or have biases – such as affinity bias or the motherhood bias – altered the trajectory of career paths? Clearly more opportunities for study exist on causation and correlation of the disparity. 

Sistering: Why are Women Different?

Women experience the paramedical workplace differently due to biases, microaggressions, and systemic barriers and are six times more likely to experience a patient-initiated violent injury. (3, 4, 5, 6) Various studies of pandemics have found that the health care workers most likely to experience negative psychological outcomes during outbreaks were women. (7, 8) Women also demonstrate higher empathy scores during paramedic education, and a review of international healthcare professionals found that the specific challenges women in healthcare face are intertwined between family responsibilities, workplace environments, and effects of stereotyping. (9, 10)

Pandemic notwithstanding, the need for sistering exists within the core structure of EMS systems because of the barriers women face in career development. There are two main theories that explain career progression: contest mobility theory and sponsored mobility theory. In essence, contest mobility suggests that the harder you work at your job, the more success you will see, whereas sponsored mobility suggests relationships with supervisors and peers is a better indicator (5). In a review of American career (non-volunteer) paramedics, increased education, experience, and hours worked all meant increases in salary – unless you were a woman. Compensation for women remained consistently lower than men with similar comparison points. (5) Due to subjective constraints surrounding sponsored mobility theory, the study used “career satisfaction” to evaluate sponsored mobility theory in the same population. Although women received lower compensation across the board, subjectively they tended to have the same or better satisfaction with their careers. (5) Essentially, “female EMTs may be receiving support and sponsored mobility, leading to subjective career success, but this does not afford them the objective career success (that is, a higher salary).” (5). The authors advocate for organizations to critically examine pay structures to ensure equity.

Training, mentoring, and coaching are identified as organizational necessities to align objective and subjective career success for women (5). Although most Canadian EMS services are union-based with strict, seniority-based pay structures that may protect seniority despite maternity leave or part time work, more research is needed on how other contributors to career success affect female (and minority) paramedics. Areas in which women are underrepresented (such as tactical EMS, public safety, incident/chemical response, or education/training roles) should be examined, as well as non-unionized or management roles that lie outside of the regulated pay structures that unions provide. In health care organizations around the world, research speaks to the need for policy to specifically address inequality. (10)

Sistering: Purposeful, Structured Organizational Support for All Genders

The military – both Canadian and American – provides us with specific examples in which sistering is used to support members working in stressful situations. In the Canadian Forces, new recruits are often placed in pairings called fireteams when completing their Basic Military Qualification courses. (11, 12) These pairings are expected to always act together: you never leave a fireteam partner behind. If a larger group is lining up for parade, inspection, or any group task, no one should arrive late alone and if a single member arrived late, their fireteam partner would be asked why they allowed that to happen – why did they leave their partner behind? 

In 2019, the Departments of Anesthesiology and Psychiatry and Behavioral Sciences at the University of Minnesota Medical Center adapted the US Military’s Battle Buddies program to create pre-emptive resiliency-promoting strategies at the individual and organizational levels for healthcare workers in the pandemic. Each person entering a stressful work environment is assigned a battle buddy who has a similar level of responsibility, life experience, and authority. New, young recruits are paired with other new, young recruits, mid-career practitioners with like, and commanders are paired with commanders. (13) 

A battle buddy (which could provide a framework for sistering in paramedicine) works alongside their colleague – stepping around the proverbial land mines of working in a pandemic – experiencing the same events from a similar lens and with the same level of experience and responsibility. They are matched on demographics, professional roles, and seniority. This partnership allows each individual to help the other identify stressors on and off the job that may be contributing to operational stress by focusing on listening, validating experiences, and providing feedback. Early anecdotal evidence from this project is positive when adapted for healthcare workers and tied into a larger mental health program. In the US Army it had an 80% satisfaction rate and reduced suicide rates. (13)

The organizational strategies of sistering could vary by situation from a structured program to individual, daily options supported by a broader program. These strategies must pervade all levels of an organization to truly have a positive effect and may involve paramedics engaging support related to the area of need: union, mental health professionals, physicians, legal advice.

Tangible Applications of Sistering in Paramedicine

The following are presented as potential examples that may sister women – and in fact, all practitioners – in paramedicine.

Sistering means we all get home at the end of the day, we all come home safe.

Battle buddy check ins occur two to three times per week for a maximum of 10 minutes and involve questions like: What is hardest right now? What went well today? What challenges are you facing with sleep/rest, exercise, healthy nutrition? This self-reflection can build awareness, foster resiliency and may help frontline staff figure out adaptive ways to cope in adverse environments. (13)

Sistering creates bonds for healthy mind and body states.

A lack of social support is more strongly related to the development of PTSD in women, and the current global state has removed many supports, not just for healthcare workers (or women) (14). Developing social support must be much more purposeful. The hormone oxytocin, released during pleasant social contact, is crucial to recovery from stress responses and mediates the fear response while also reducing emotional numbing. Research shows that oxytocin (combined with a complex of other neuropeptides and hormones) may hold a key role in recovery from stress through bonding and socialization. (14) Formal or informal partnerships – like stable on-car partners – promote the building and maintenance of social supports, which in turn create a strong, stable workforce.

Sisterhood can be developed at the frontline level through formalized support programs.

Without individual initiative and participation, structural support will collapse like a building without a foundation. Developing collective efficacy, the idea that you are a part of a group that can effectively enact change, or has control over their environment, is crucial to surviving mass traumas (such as pandemics, as seen in 2003 SARS outbreak in Hong Kong). Creating structures through programs like battle buddies or fireteam partners and focusing on positive, self-compassionate, hopeful actions is an antidote for negative emotions and builds resiliency. (13)

Sistering can mean using your voice to advocate for equity.

As mentioned above, several studies (3, 4, 5, 10) indicate that disparity by gender exists and policy changes are required, which only come through persistent advocacy. Organizations like Canadian Women in Medicine that celebrate the first female physician in 1875, or Alberta Health Services’ Virtual Nursing Mentorship Network both help create space for mentoring, partnerships, and professional development. Unions have historically played a role in supporting women-driving initiatives (it was the Canadian Union of Postal Workers in 1981 who won the right to paid maternity leave, which was expanded to all Canadians). (15) Groups formed for the purpose of advocacy and support within a profession become self-fulfilling by creating the environments within their ranks that they hope to create in the profession, for all practitioners. 

Concluding Thoughts

As Georgette Eaton notes in her article from the 2020 special issue of Women in Canadian Paramedicine, “bias still exists through the lack of attention to certain interests and experiences deemed to be ‘feminine’, rather than explicit denigration of them” (16). It is not that feminine terms, specifically, are different, it is that anything not inherently masculine is still considered a deviation from the norm. Perhaps that is why we should start using the term sistering regardless of gender to denote supports that hold structures together: to challenge the notion that strength is innately masculine or exists in any binary form at all.

This concept of sistering can be applied in the EMS environment to promote uplifting, strengthening, and supporting our colleagues – of all genders. Although active supports are required for women to achieve career equity, all paramedics will benefit when sistering is built into the culture. Now, as we live and work in a global pandemic, this is needed more than ever. 


The author would like to acknowledge and thank Les Fisher and Kathleen Fraser for their time in reviewing this article.


  1. Doyle, G. The Best Part of Life. SALT Project 2016.
  2. Porter, A, Bourgeault, I. Gender, workforce and health system change in Canada. Canadian Institute for Health Information. November 2017.
  3. Levine R. Longitudinal Emergency Medical Technician Attributes and Demographic Study (LEADS) Design and Methodology. Prehospital and Disaster Medicine. Cambridge University Press; 2016;31(S1):S7–S17.
  4. Abdela, A, Cook H, Vannistelrooy J. Choose To Challenge Lunch and Learn. Educational session presented online for International Women’s Day. 2021 March 8. Calgary, AB.
  5. Russ-Eft D, Dickison P, Levine R. Examining Career Success of Minority and Women Emergency Medical Technicians (EMTs): A LEADS Project. Human Resource Development Quarterly. Wiley Periodicals, Inc.; 2008;Vol 19, no.4. DOI: 10.1002/hrdq.1242
  6. Taylor J, Barnes B, Davis A, Wright J, Widman S, LeVasseur M. Expecting the Unexpected: A Mixed Methods Study of Violence to EMS Responders in an Urban Fire Department. The American Journal of Industrial Medicine 59:150-163 (2016) Wiley Periodicals.
  7. Zhou Z, Shabei X, Hui W, et al. COVID-19 in Wuhan: Sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers, EClinicalMedicine, Volume 24,2020,100443,ISSN 2589-5370,
  8. Hennein R, Mew E, Lowe S. Socio-ecological predictors of mental health outcomes among healthcare workers during the COVID-19 pandemic in the United States PLOS ONE. 5 Feb 2021.
  9. Pagano A, Robinson K, Ricketts C, Cundy-Jones J, Henderson L, Cartwright W, Batt A. Empathy Levels in Canadian Paramedic Students: A Longitudinal Study. International Journal of Caring Sciences. 2018 Vol. 11 Issue 3. P1492
  10. ALobaid A, Gosling C, Khasawneh E, McKenna L, Williams B. Challenges Faced by Female Healthcare Professionals in the Workforce: A Scoping Review. Journal of Multidisciplinary Healthcare. 2020:13 681-691
  11. Martin D. Fire Team Partners Forever. Canadian Military News. Aug 2018
  12. McInnes M. First Principles and the Generation of Armoured Fighting Power. Canadian Army Journal. CAF: 17.3.
  13. Albott C, Wozniak J, McGlinch B, Wall M, Gold B, Vinogradov S. Battle Buddies: Rapid Deployment of a Psychological Resilience Intervention for Health Care Workers During the Coronovirus Disease 2019 Pandemic. International Anesthesia Research Society. 2020. DOI: 10.123
  14. Olff, M. Bonding after trauma: on the role of social support and the oxytocin system in traumatic stress. European Journal of Psychotraumatology 2012, 3:18597
  15. Canadian Labour Congress. Maternity and parental benefits.
  16. Eaton, G. Change the Narrative. Canadian Paramedicine. April 2020
Heather Cook

Heather Cook

Heather Cook is an Advanced Care Paramedic, HSAA Local Unit Chair, and Governance Committee Member of the EMS Women in Leadership Workforce Leadership Group with Alberta Health Services. She is formerly a published author and has spent the last 10 years working as a frontline paramedic in Alberta. She’s currently enrolled in the Bachelor of Paramedicine with Charles Sturt University.
Twitter: @i_am_the_storm_

Heather Cook

Heather Cook

Heather Cook is an Advanced Care Paramedic, HSAA Local Unit Chair, and Governance Committee Member of the EMS Women in Leadership Workforce Leadership Group with Alberta Health Services. She is formerly a published author and has spent the last 10 years working as a frontline paramedic in Alberta. She’s currently enrolled in the Bachelor of Paramedicine with Charles Sturt University.
Twitter: @i_am_the_storm_

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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