Research Project

1. Abstract

2. Introduction includes (Defining the research question, Problem Statement, Objectives)

3. Methodology to do: Literature Reviews and Analysis

4. Compare previous articles: Objective, method, result, limitations, conclusion (Make tables out of this).

5. Analyze and combine the information.

6. Result to the research question and highlight the gab in current articles.

7. Concluding remark.

8. Figures and Tabels.

the Saudi electronic university

College of Health Sciences – Master’s Program in Health Care Administration

Guidelines for writing a research project

First, the cover page template

The university logo

Saudi Electronic University

Health Sciences Collage

Master of Healthcare Administration

HCM 600 Research Project

Research title

——————————

A Research Project

Submitted in Partial fulfillment of the

Requirements for the Degree Of

MSc of Healthcare Management

Presented by

Student name ——————————-

Supervisor:

Supervisor name——– ———————

Date ——————

Second: the contents page

Table of Contents

Table of Figures iii

Table of Tables iv

Declaration………………………………………………………………………….v

1. Introduction (500 words) 1

2. Literature Review (1500 words) 3

3. Objectives (100 words)

4. Methods (1000 words)

5. Results (1000 words)

6. Discussion (1000 words)

7

. Conclusionm (500 words)

8. Recommendation (500 words)

9. References (More recent not more than 10 years)

10. Appendixes

Third: How to write

1- English language

2- On the computer and send an email to the supervisor

3- Printing with laser printers

4- Writing on one side of each piece of paper

5- Font type and headings

– The writing is in Font size 12, type Times New Roman

– Titles are written in the middle of the page using Font Size 18(uppercase)

– Headlines are with Font Size 16 Bold

– Headings under headlines are using Font Size 14 Bold

– Side title is with Font Size 12 Bold

Table titles using Font Size 12 Bold at the top of the table while figure titles using Font Size 12 Bold at the bottom of the figure

6- Lines: The writing should be a line and a half space between the lines

7- Margins: 3 cm on the right of the page and 2 cm on the left, in consideration of the binding process

8- Pagination: middle of the page down

9- Shapes:

– The figure number must be mentioned and referred to in the body of the search, and it is placed with a serial number for each figure in parentheses (Figure 1, 2, 3…)

Shapes include graphs and photos

– The figure is placed in the closest writing location to the pages in which the figure is mentioned

– The number is written under the figure, preceded by the word “shape” and followed by two dots Figure 1: Then the title of the figure

The figures pages are numbered in sequence with the rest of the research project pages

10. Tables

The table number must be mentioned and explained in the body of the research

– The table shall be placed in the nearest place after its mention in the body of the writing of the pages in which the table is mentioned

Write the table title preceded by the word Table followed by its number Table 1

– The sequence of table numbers according to their occurrence in the pages of the research project (1,2,3,—-)

Fifth: The content of the research project

– Title page containing the name of the Saudi Electronic University – College of Health Sciences – Master of Health Care Administration Program), the title of the research, the name of the student and the supervisor and his scientific rank

– Declaration page, in which the student submits a declaration that the research has been done and has not previously been published

– Acknowledgment page in which thanks are given to those who provide scientific and material assistance

List of Abbreviations

List of contents

List of tables

List of figures

Abstract (-Summary)

The research project includes an abstract in Arabic and English within 200 words, and a summary of the research in English and in Arabic 1000 words to be placed at the end of the research project

Sixth: Classification of the research project

Chapter One: Introduction

It includes the research problem, its justifications, and its research procedures, provided that it does not exceed a maximum of one and a half pages (500 words).

Chapter Two: Theoretical Framework and Studies (Literature Review)

It includes the scientific background of the research, reviewing what was published about it, clarifying the importance and reasons for selection, so that the number of pages for this chapter does not exceed 30% of the volume of the research project (1500 words).

Chapter Three: Research Objectives

It includes the general objective and specific objectives of the research project (100 words).

Chapter Four: Materials and Methods

This chapter is limited to mentioning experimental and theoretical methods, in which scientific experiments are explained and the system and method that was followed (1000 words) are explained.

Chapter Five: Results

It includes a description of the most important results obtained and their statement in the form of tables and graphs, in addition to an explanation of the results (1000 words).

Chapter Six: Discussion

It includes a statement of the importance of the results, their applications and repercussions, and a comparison of the results with what was previously obtained from other researchers in the published research, the points of agreement and differences, if any, and the researcher’s opinion on the reasons for this (the results and discussion may be placed in one chapter) – (1000 words)

Conclusions

It includes a summary of the findings (500 words).

Recommendations: ((Recommendation

The researcher’s recommendation on how to apply and use the results includes (500 words)

References

It is taken into account that the references are recent not less than ten years, and a list of references is placed at the end of the research project, numbered according to their presence in the body of the project. The method adopted by the university, which includes

– The name of the author and it is placed in his family name, then followed by the letter or initials of his other names, and if the reference has more than one author, all are mentioned in the same way and according to the sequence contained in the original reference

– The title of the book and in the articles the full title of the research and the name of the journal are mentioned

Place of publication in the case of the book

– Year of Publication

– Volume-number-number-first and last page

Appendixes

The tools that were used in the study include questionnaires, pictures, and others

Seventh: General notes

1- Each section or chapter begins with a new page

2- A separator sheet is placed at the beginning of each chapter and printed on it in bold type is the word of the first chapter, the introduction, the second chapter, the previous studies, and so on for the rest of the chapters.

7

The impact of leadership on the quality of care for emergency medical services in healthcare organizations in

Saudi Arabia

A research proposal

Submitted for the degree of MSc.

Of healthcare management

Presented by

Abdulazeez Abdullah M Albaradei

Supervisor

Dr. Mohammed A. Almohaithef

Date

14

/2/2022

Introduction

Studies connecting leadership with the quality of health organizations services are still rare. On the other hand many studies have shown that leadership has a great contribution to the performance of an organization. Therefore, this study will be utilized to develop a framework of service quality in health organizations which incorporates the role of leadership. The research will be based on a systematic review through a comparison of different studies in this field. Also, data will be collected by a systematic review on the perspective of the impact of leadership on health care quality in health organizations. But the basic is the formation of a systematic review through the comparison with the previous studies in this field. The results expected to show that there is effect of leadership on the quality of service.

Background

Effective leadership of healthcare professionals is critical for strengthening quality & integration of care. The requirement for elevated coordination in patient care & higher quality care at lower costs has made it essential for EMS agencies to have in-place quality control or quality enchantment programs that depend on key performance indicators to continuously monitor the system’s overall performance and the effectiveness of the various pre health organizations interventions. The IOM described quality as “the degree to what health services for individuals & populations elevate the likelihood of desired health outcomes and are consistent with recent professional knowledge” and showed six dimensions of quality care: a care that is safe, patient, timely, effective, efficient & equitable.(IOM,2006).

Factors that affect the level of service quality include human resources management, HR, organizational culture, leadership & others. Job satisfaction and organizational commitment allegedly played a role in determining the influence of leadership on the service quality. Leadership was one of different factor that mostly studied, but it is not clear how the leadership can affect the service quality. Evaluating quality of care is significant as patient satisfaction is discussed by the service quality. (Duggirala et al., 2008)

Quality criteria can be varied according to patient preference. It is therefore significant for health organizations to indicate the patient’s preferences so as to give quality patient care in line with expectations. The definition of service quality is the hope, desire, something that should be delivered by service providers, normative expectations, ideal standard, the desired service, and service levels known by consumers.

On the other hand, Leadership is a person’s ability to lead others, the ability to contribute to the achieve goals & organizational success. (Choi et al., 2006).also Blankenship described that leadership is the capability of a leader to arrive at the expected results. (Blankenship et al., 2010)

The Kingdom of Saudi Arabia is listed as the 14th largest country in the world with an area of 2, 2400,000 sq.km (Ewan et al., 2013).The health care as an organized structure began in 1926 in Mecca with the issuance of a decree establishing “health care department” by the first King of the country, King Abdul-‘Aziz which was one of the highest priorities to him. The development of Emergency medicine, as a specialty in Saudi Arabia is important. (Mufti et al., 2000) .The concept of Emergency medical services wasn’t strange to the Kingdom; it was brought firstly into the country by a charitable help society back which was the pre formation of SRCA.

Problem Statement

How leadership impact the quality of care for emergency medical services in healthcare organizations is not widely understood. The topic of how leadership in EMS is learned in different nations has not been well- discussed.

Within EMS publications, EMS professionals have described different styles or theories of leadership and applied the theories to the profession. There remains an elevate level of importance and interest in research to differentiate and substantiate EMS leadership. The critical nature of understanding how leadership affect the quality of EMS is not limited to one country, but is required internationally as the role of EMS during emergencies is a growing topic in international emergency medicine. Thus, the requirement for further understanding on leadership in EMS at the international level is recognized as an unmet requirement. (Brink et al., 2009)

Aims

This study aims to achieve the impact and the association among leadership and healthcare quality measures in Saudi Arabia organizations. To understand the nature of leadership work of the health organizations managers in order to examine their perceptions of the most essential roles, skills and training courses as health organizations managers. Also to identify the challenges, obstacles and issues facing health organizations leaders.

Objectives

The objectives of this study are the following:-

1-To investigate the strong influence of leadership on the quality of service of care for emergency medical services in healthcare organizations.

2-How the leadership can affect the service quality.

3-To determine the influence of leadership effectiveness on health-care service quality Care.

4-To determine whether there is a need to improve the quality of health.

5-To determine whether the efficacy of leadership has an impact on employee satisfaction.

Methods and Methodology

The systematic review will be designed & conducted in line with the published guidelines for reporting systematic reviews and meta-analyses. A systematic review of the leadership influence on the quality of healthcare will be performed. The review question is: “what is the impact of leadership in settings of healthcare & quality of care?” A systematic, comprehensive bibliographic search will be performed out in the National Library of Medicine (Medline) and EMBASE databases for the time between 2012–2021 in the PubMed interface.

Search terms that will be chosen from the USNML Institutes of Health list of Medical Subject Headings (MeSH) for 2015. The included MeSH terms are: “Leaders”; “Leadership”; “Managers”; “Management style”; “Leadership style”; “Organizational style”; “Organizational culture/climate”; “Leadership Effectiveness”; “Quality of healthcare”; “Patient outcome Assessment”; “Quality indicators, Healthcare”; “Healthcare quality, Access and Evaluation”; and “Quality Assurance, Healthcare”. References that will be utilized by each identified study will also checked and involved in the study according to the eligibility criteria.

Five main inclusion criteria will be included:

• Papers published in peer-reviewed journal

• Papers written in the English language

• Papers published from 2012 to 2021 (focus on more recent knowledge)

• Human epidemiological studies

• Studies used a quantitative methodology reporting the leadership style and healthcare quality measures

Studies that do not meet the above criteria will exclude, while those that comply with the inclusion criteria will be listed and further reviewed.

Studies will be evaluated and appraised, Literature screening (a three-stage approach-exclusion by reading the title, the abstract, and the full text) and Data will be extracted systematically from each retrieved study, utilizing a predesigned standard data collection. The following information will be extracted from each one of the involved studies: authors, year of conduction, study design, subjects, country ,population, research purpose, leadership style definition, outcome definition, and major findings.

Conducting a systematic review about the influence of leadership on quality of healthcare inside and outside the health organizations.

14

A brief description of 10 related articles are shown on Table 1.

Saudi Arabia

Main Findings	Outcome	Aim of the study	Main Study Characteristics	Country	Study’s Name	Author et al(year)
In the Makkah and Al Madinah Al Munawarah regions, the SRCA was well prepared to deal with MICs. The median score for Riyadh, the North Borders, the Eastern Region, Tabuk, Jazan, Hail, and Qasim was 3. A median score of 2 was assigned to the remaining regions. Some critical issues were not addressed in this study.	The findings back with prior research that found that EMS staff in Saudi Arabia lacked crisis management training. 22 Medical directors are major participants in MCI management, and they should set guidelines as well as engage in emergency preparedness planning. 23 The Saudi Red Crescent Authority needed EMS advisors who could oversee all EMS personnel’s daily operations and analyses crisis situations. The total median scores and the number of physicians in the center had a modest positive link in this study, indicating a lower personnel benchmark score. The second benchmark, and one of the most essential variables in incident management, was infrastructure.	To assess the mass casualty incident (MCI) preparedness of pre-hospital care providers in Saudi Arabia and to identify and highlight their strengths and weaknesses when responding to MCIs.	This cross-sectional descriptive quantitative analysis was conducted between January 2017 and 2018 and included all Saudi Red Crescent Authority (SRCA) general administration branches in 13 regions in Saudi Arabia. The modified version of the emergency medical specialists (EMS) incident response and readiness assessment (EIRRA) tool was used in this study.		Saudi Arabia	Assessing the pre-hospital care preparedness to face mass casualty incident in Saudi Arabia	1.Alotaibi, & et al., (2019)
Paramedics respond to cardiac arrest emergencies on a regular basis, following carefully defined clinical protocols as they work together to resuscitate patients. The narratives offered a serve as key examples of how managers and employees respond to conflict. Deviance.	This article reports only two service interactions illustrating conflict in manager-worker relations, and is not representative of a full body of these interactions or incidents in street-level EMS. The stories presented here are not fact, but rather individually constructed interpretations of events. The results of managing for compliance versus managing for outcomes may be tremendously different, and the implications for individual patients may be great.	To investigate the interactions between street-level personnel and formal authority figures during emergency medical service provision. The findings show that there are both instances of compliance and disobedience to managerial directives. When the patient’s clinical demands were generally obvious and the directions’ consequences were sufficiently congruent with the paramedic’s preconceived conceptions of acceptable response, compliant behavior was evident. When a patient’s positive outcomes were contingent on disobeying orders, there was a clear deviation from managerial directives. Contributions to theory and practice are reviewed, as well as future research directions.	Qualitative methods (Gilboy, 1992; Maynard-Moody and Musheno, 2003; Newman, Guy, and Mastracci, 2009; Sandfort, 2000; Vinzant and Crothers, 1998), mixed methods (Oberfield, 2010; Riccucci, 2005), and quantitative experimental studies have all been used in empirical research into the unique nature of street-level bureaucrats (Scott, 1997). This study provides a beginning examination of influence and discretion in frontline leader-worker interactions, both of which are essentially subjective concepts. As a result, for this investigation, an interpretative methodological base is acceptable This exploratory study use narrative analysis to capture multiple interconnected, complicated, and mostly unexplored ideas as they arise in frontline EMS practitioners’ actual actions (Yin, 1994). The narrative of a street-level EMS worker caring for a patient in the face of physical, social, and clinical contingencies serves as the study’s unit of analysis. “Naturalistic ones [with] high time pressure, high information content and changing conditions” are how Klein, Calderwood, and Macgregor (1989) describe such settings (462). The researcher utilize tales in a similar way to Klein (1998), who observes that “stories include many different lessons and are valuable as a type of virtual experience for persons who did not witness the occurrence” (179)	International Review of Public Administrat-ion.	Leadership in Street-Level Bureaucracy: An Exploratory Study of Supervisor-Worker Interactions in Emergency Medical Services	2-Henderson&et al ., (2013)
A synthesizing argument has been spread based on a critical interpretative synthesis of literature that implies leadership is a social construct. There will be no one-size-fits-all solution that will work for everyone (Allio 2009). However, the research suggests that any leadership style has a basic balance of four elements: the leader, the follower, common objectives, and the situation. Individual paramedic leaders must evaluate how each of the aspects interacts with one another in order to be effective. It is stated that if the paramedic leader can achieve this, regardless of the style they use, they will be successful.	Leadership is a complicated topic that has been researched extensively over time. Its significance in the development of successful and efficient organizations has been debated and re-examined several times. This has resulted in a plethora of study aimed at determining the best way to effective leadership. Despite a lot of effort and effort, no one solution has been identified that gives an answer to this question; instead, a diverse set of approaches has been developed.	to help people transform; to assist them in become the best they can be, so that the organization and the individuals can work together to achieve their goals. It had the potential to accomplish far more than had been anticipated. The model incorporated concern for ethics, norms, and meeting followers’ needs.	There appears to be a continual need for excellent leaders and good leadership to guide us out of our challenges in recent times. David Cameron (2011), for example, declared at the Conservative Party Conference in 2011: “I “In these challenging times, we require leadership to get our economy going and our society functioning. Leadership is effective.” It is quite simple to talk eloquently about the virtues of leadership; for millennia, people have been studying and striving to do so. The problem is that, while leadership is a notion that most people intuitively grasp, defining what excellent leadership is or implies becomes extremely challenging (Crainer1998). Who decides when ‘leadership works,’ as Cameron put it? People, according to Northouse (2007)	Sheffield Hallam University	Understanding an alternative approach to paramedic leadership	3-Johnson, & et al.,( 2018)
The research revealed four significant elements regarding paramedics’ abilities to engage in leadership on the front lines of treatment. Table 2 provides an overview of these concepts. When the themes are examined, they appear to reflect the predecessors of shared leadership, shared leadership practices, and the structural circumstances that allow shared leadership to arise. Below, we’ll go through each concept in further depth.	Leadership is not recognized as a major competency of competency for all levels of paramedics in Canada . The lack of attention paid to leadership development among paramedics extends beyond Canada and is a global issue. Paramedic associations and organizations might consider implementing leadership modules as part of their core curriculum and training. Health care organizations may benefit from having a culture of shared leadership to bolster patient care.	Few empirical researches on shared leadership in health care settings have been conducted too far. Despite paramedics’ critical role in leading on the front lines of treatment, there are few studies of leadership in paramedicine. We look at what it means to informally lead on the front lines of patient care using paramedics as an example, with a focus on paramedics responding outside of the hospital.	The study performed semi structured interviews (Q&A) with 29 paramedics from central and eastern Canada’s emergency medical services. The goal of qualitative research is to gain a better understanding of the lived experiences of those who work on the front lines of patient care. The participants’ paramedicine experience ranged from 3 to 30 years, with 75.7 percent of men and 24.3 percent of women being questioned. We’re looking into the many types of leadership that occurs on the front lines of care, not only official or formal leadership positions, but the kind of leadership that paramedics conduct on a daily basis. The interviews were semistructured in the sense that we created questions before collecting data, but we changed them and asked various questions depending on the flow of the conversation.	Canada	Leading on the edge: The nature of paramedic leadership at the front line of care.	4-Danielle &et al., (2018)
In each round, all key competence statements received a majority vote, and all issues received more than the required 75 percent consensus. Between rounds, the degree of consensus increased, with a minimum rise of 0.2 percent for item 9, indicating the maximum level of consensus attainable. A response rate of 70% is considered the minimum acceptable rate for maintaining research rigour.	The first research to reflect the perspectives of important experts and stakeholders in Saudi EMS in order to develop an agreement on a core competence framework. The Delphi research met all of the criteria for majority, consensus, stability, and response rate. In Saudi Arabia, paramedics are expected to have certain fundamental competences. However, the findings of the study do not provide a definitive blueprint for the development of EMS courses. To build a full picture, more study and statistical modelling based on bigger samples is suggested.	To obtain agreement from a professional group on the desired core skills for EMS. In order to build a core competence framework for Saudi Arabian EMS, bachelor’s degree graduates in Saudi Arabia were recruited.	Expert views on essential competences for Saudi EMS Bachelor degree graduates were gathered using the Delphi technique. The instrument was written in English, and two native Arabic speakers were among the participants. Only 17 of the 20 expert potential participants decided to take part in the study. The whole survey was completed by all participants, and there were no responses to the optional open-ended question. Minimum, maximum, central tendency (mean), amount of dispersion (standard deviation), and number and percentage of replies to each of the question levels were all included in the statistical feedback report. The demographic information was left out of the feedback report, which was confined to collective answers. According to Keeney’s advice, the adopted consensus level was 75%. (15). While all fundamental competencies are important,	Australia	Emergency medical services core competencies: a Delphi study.	5- Alshammari, Talal & et al., (2019).
Leadership effectiveness is an important tool for organizations in order to inspire, mobilize, communicate and motivate their followers. Quality of health care service relates to enhancing and enhancing health care services, increasing efficiency and reducing mistakes and costs. However, the findings revealed that leadership effectiveness was substantially connected with service quality (p 0.05). The correlation between the two variables, however, is quite poor (r = 0.103). The respondents rated leadership effectiveness, service quality, and overall service quality as good in Table 3. Patients were asked to rate HUSM’s overall service quality on a scale of 1 to 10, with 1 being the worst and 10 being the best (very high). The majority of responders (99.2%) were happy with the services, according to the results. Only a small percentage of people picked a scale lower than 5. (0.8) percent In this study, the Spearman’s Rho Correlation analysis was used. The findings revealed that leadership effectiveness was substantially connected with service quality (p 0.05).relationship between leadership effectiveness and service quality is very weak.	To discover the impact of leadership effectiveness on the quality of health care service at The university hospital in Kelantan, Malaysia.	The research was carried out at the “Hospital University Saints Malaysia” (HUSM), a teaching institution in Kubang Kerian, Kelantan, Malaysia. The questionnaire was distributed to in-patients and hospital workers by the researcher. The researcher visited with each in-patient and staff member individually to explain the study’s goal. The study employed a quantitative approach. A cross-sectional research approach was adopted in this study. It employed two sorts of survey instruments in this situation. The Leadership Practices Inventory (LPI) survey, designed by Jim Kouzes and Barry Posner, was used to assess leadership effectiveness among doctors, nurses, and administrators (2000). The study employed a commonly used questionnaire, the Consumer Assessment of Health Care Providers and Systems, or CAHPS, for the in-patient survey.	Malaysia.	The Impact of Leadership Effectiveness on the Quality of Health Care Service at Universiti Sains Malaysia Hospital (HUSM), Kubang Kerian, Kelantan, Malaysia	6-Abdul Rahman,Wan,(2017)
The number of patients transferred from the scene to the hospital for medical and trauma reasons differed significantly between male and female EMS users, according to the findings. For both sexes, basic support was significantly more prevalent on the scene than advanced care, with 551 men and 237 women receiving basic help compared to only eight male and four female patients receiving advanced treatment. Essential patient information for both male and female EMS users, as well as the event category “no medical care provided.” In the city, there were 295 (73.8%) male EMS users and 105 (26.3%) female EMS users. The urban group had a mean age of 42.75 years, whereas the rural group had a mean age of 39.72 years.	A number of important concerns were discovered after analyzing this cross-sectional dataset by both geographic area and gender. One of the most significant distinctions was that rural EMS users were more likely to have trauma-related situations that necessitated EMS transport, whereas medical reasons were more prevalent among urban EMS users. Men also used EMS at a substantially greater rate than women, and were more likely to be transferred to the hospital after a call. The current study did not have the resources to investigate the reasons underlying these findings, thus more research is needed to properly understand the results.	To provide a broad picture of how patients used prehospital EMS in the Riyadh region of Saudi Arabia, with a particular focus on any differences in patient behavior. Acomparison between urban and rural settings There was no research in this field found in a literature search. Only a few research outside the United States have been undertaken on this topic, according to Riyadh. EMS results in urban and rural areas were examined in Europe and Australia. This piece is part of a larger project. EMS performance in rural and urban settings is being investigated as part of a study project. Saudi Arabian nationals.	The Saudi Red Crescent Authority EMS in the Kingdom of Saudi Arabia gathered emergency patient records (EPRs) over the course of a year, from January 1, 2017, to December 31, 2017. The initiative intended to concentrate on data from the Makkah administrative region, The Saudi Red Crescent Authority EMS in the Kingdom of Saudi Arabia gathered emergency patient records (EPRs) over the course of a year, from January 1, 2017, to December 31, 2017. The initiative intended to concentrate on data from the Makkah administrative region, which has the greatest population base and the highest rates of EMS transportation. Riyadh was chosen as the data source since it has the second-highest number of transferred cases. The 800-item dataset came from hardcopy EPRs generated after an EMS response to an emergency call-out. The data was manually transcribed once each hard copy was physically read. The files were chosen with the help of a Saudi Red Crescent supervisor using a computer-generated random number list. Statistics that are simple and descriptive which has the greatest population base and the highest rates of EMS transportation. Riyadh was chosen as the data source since it has the second-highest number of transferred cases. The 800-item dataset came from hardcopy EPRs generated after an EMS response to an emergency call-out. The data was manually transcribed once each hard copy was physically read.The files were chosen with the help of a Saudi Red Crescent supervisor using a computer-generated random number list.	Utilization of prehospital emergency medical services in Saudi Arabia: An urban versus rural comparison, : Journal of Emergency Medicine, Trauma and Acute Care.	7-Alanazy, A., et al.,(2021

Most respondents suggested that they thought clinical leaders had the skills and abilities to do their job. Most thought clinical leaders were involved in team work, the generation of new ideas, were great communicators and involved others appropriately. Most didn’t care where their experience was from or what sort of experience it was as long as they had valid road side experience. Most didn’t value research insights or qualifications. What mattered was that the values of the clinical leaders were matched by their actions and abilities.	It is hoped that with a better understanding of clinical leadership and how it is perceived by paramedics and ambulance officers, they will be able to play a more effective part in service improvement, impacting positively on pre-hospital care delivery. As well, a more effective understanding will be gained of how clinical leadership impacts on the effectiveness and delivery of pre-hospital care and how the ambulance service can bolster and support greater clinical leadership and service improvement.	To identify how clinical leadership is perceived by paramedics in the course of their everyday work and the effectiveness and consequences of the application of clinical leadership in pre-hospital care delivery.	A questionnaire (with a supporting information letter) was distributed via inservice training sessions to all St. John Ambulance operational staff in WA between February 2010 and November 2010 (n = 250). The methodological principals supporting the study are based on phenomenology. Analysis of the quantitative data was via SPSS software and qualitative data was analysed by spreadsheet and word documents.	Ausralia	Perceptions of clinical leadership in the St. John Ambulance Service in WA	8- Stanley, D., Cuthbertson, J., & Latimer, K. (2012)
The National Institute for Health and Care Excellence (NICE, or the Institute) provides guidance to the National Health Service in England on the clinical and cost effectiveness of selected new and established technologies. According to NICE, the expression for health effects should be in QALYs. The EQ 5D is their preferred measure for health-related quality of life in adults.	This article reports on one of the few RCTs undertaken regarding CP. Among its unique features, the participant group presented a great challenge for the caregivers in attempting to conserve quality of life and reduce utilization of acute care facilities as well as LTC institutions. Where other studies have concentrated on the use of medics in the home to address acute issues and attempt to provide local care rather than transport to ERs, our study focussed on regular visitation and monitoring to alleviate the trajectory of chronic disease.	to determine whether communityparamedicine services (the intervention through home visits) would have a positive economic impact through influencing self-perceived qualityof life and determining a monetized value.	In addition to the rural setting in Renfrew, this study included new CP service provision and participation in the urban areas of Hastings County, Ontario. Paramedics from the Quinte Emergency Medical Services detachment in Belleville received the same supplemental training and were coached by the Renfrew CP prior to commencing home-based practice. A total of 200 eligible clients (120 for Hastings and 80 for Renfrew) were recruited in early 2015 and randomly assigned to either the intervention group (receiving community paramedicine services) or the control group (receiving conventional treatment). All of these clients had used a Paramedic Service ambulance to go to a hospital emergency room (ER) three times or more in the preceding year, and had one or more of the following chronic conditions: chronic obstructive pulmonary disorder, congestive heart failure, diabetes, hypertension or stroke.	Eastern Ontario.	Conserving Quality of Life through Community Paramedics	9- Ashton, C., Duffie, D., & Millar, J. (2017).
Transformational leadership style has significant influence and positive toward employee performance. This gives the meaning that transformational leadership style has a direct role to improve performance to be generated at organization.	1) Transformational leadership style with its indicator which used are: the influence of ideal, intellectual stimulation, leader behavior, consideration of individual has significant influence and positively to motivation. With significant stage (0.000). Transformational leadership style has direct role to increase motivation that will produce by employees to organization. 2) Transformational leadership style has significant influence and negative towards Burnout. With significantly stage of (0.007). This thing showed that transformational leadership style has great capability to prevent Burnout. Direct influence more strong than indirect influence. This proved that variable intervening that mediates variable transformational leadership style with burnout cannot neglect.	to describe and analyze the influence of transformational leadership styles, motivation, burnout, and job satisfaction and employee performance. The unit of analysis is nursing paramedic at a hospital in Malang Raya.	This explanatory research is a kind of resarch that try to explain relationship among variables through hypothesis test. Unit of analysis in this research is paramedics of Malang hospitals. Research population is Malang hospitals that consist of Malang Regency, Malang City and Batu Malang City. It takes 6 hospitals at Malang Raya area.Sampel of this research is nurse paramedics that use as responden. Sample size using Slovin formula with 5% of galad precision. Base on calculation with Slovin formula get 105 people as sample size.	Indonesia	The Influence of Transformational Leadership Style, Motivation, Burnout towards Job Satisfaction and Employee Performane	10- Risambessy, A., & et al., (2012).

Hypothesis

The way in which the leadership affect the quality of care for emergency medical services in health organizations.Leadership influence in Saudi Arabia organizations on the health care quality.

Excepted results

The results expected to show that there is strong influence of leadership on the quality of healthcare. This study expected to found that there is a difference in leadership approach among doctors, nurses and paramedics inside & outside the health organizations. Among doctors, charisma is a significant aspect of leadership, but among nurses, supportive approach is more important. And effect on health-related outcomes differs according to the different leadership types.

Time line

Start in February 2022 and expected to finish in May 2022

References

1. Institute of Medicine, Emergency Medical Services at a Crossroads, The National Academies Press, Washington, DC, USA, 2006.

2. Duggirala, M., Rajendran, C., Anantharaman, R.N. (2008). Patient-Perceived Dimensions of Total Quality Service In Healthcare, Benchmarking: An International Journal, Vol. 15 No. 5, Pp. 560-583

3. Choi, J.H. (2006). The Relationship Among Transformational Leadership, Organizational Outcomes, And Service Quality In The Five Major NCAA Conferences, A Record Of Study, Submitted To The Office Of Graduate Studies Of Texas A&M University, In Partial Fulfillment Of The Requirements For The Degree Of Doctor Of Education

4. Blankenship, S.L. (2010). The Consequences of Transformational Leadership And/or Transactional Leadership In Relationship To Job Satisfaction And Organizational Commitment For Active Duty Women Serving In The Air Force Medical Service, A Dissertation, School Of Business And Entrepreneurship, Nova Southeastern University

5. Brink, P., Back-Petterson, S., & Sernert, N. (2012). Group supervision as a means of developing professional competence within pre-hospital care. International Emergency Nursing, 20, 76 – 82.

6. Ewan W. Anderson, Liam D. Anderson. An Atlas of Middle Eastern Affairs. New York, Routledge; 2 edition (Oct 28, 2013)

7. Mufti, Mohammed Hassan, S., (2000). Healthcare Development Strategies in the Kingdom of Saudi Arabia. New York: Springer

8. Yin, R.K. (1994). Case study research: Design and methods, London, Sage Publications

9. Sekaran, U. (1992). Research Methods for Business : A Skill Building approach, Second Edition, John Wiley & Sons Inc., USA

10. Alanazy, A., Wark, S., Fraser, J., & Nagle, A. (2021). Utilization of prehospital emergency medical services in Saudi Arabia: An urban versus rural comparison. Journal Of Emergency Medicine, Trauma And Acute Care, 2020(2). doi: 10.5339/jemtac.2020.9

11. Alotaibi, Khalaf & Higgins, Isabel & Chan, Sally & Al otaibi, Khalaf & Chan, Sally. (2018). Original Article Nurses’ Knowledge and Attitude toward Pediatric Pain Management: A Cross-Sectional Study. Pain Management Nursing. 1-12.

12. Henderson, Alexander & Pandey, Sanjay. (2013). Leadership in Street-Level Bureaucracy: An Exploratory Study of Supervisor-Worker Interactions in Emergency Medical Services. International Review of Public Administration. 18. 7-23. 10.1080/12294659.2013.10805237.

13. Johnson, D., Bainbridge, P., & Hazard, W. (2018). Understanding an alternative approach to paramedic leadership. Journal Of Paramedic Practice, 10(8), 1-6. doi: 10.12968/jpar.2018.10.8.cpd2

14. Wan Abdul Rahman, Wan Afezah. (2017). The Impact of Leadership Effectiveness on the Quality of Health Care Service at Universiti Sains Malaysia Hospital (HUSM), Kubang Kerian, Kelantan, Malaysia. International Review of Social Sciences. 5. 407-415.

15. Alanazy, A., Wark, S., Fraser, J., & Nagle, A. (2021). Utilization of prehospital emergency medical services in Saudi Arabia: An urban versus rural comparison. Journal Of Emergency Medicine, Trauma And Acute Care, 2020(2). doi: 10.5339/jemtac.2020.9

16. Alshammari, Talal & Jennings, Paul. (2019). Emergency medical services core competencies: a Delphi study. Australasian Journal of Paramedicine. 16. 10.33151/ajp.16.688.

17. Sfantou, D., Laliotis, A., Patelarou, A., Sifaki- Pistolla, D., Matalliotakis, M., & Patelarou, E. (2017). Importance of Leadership Style towards Quality of Care Measures in Healthcare Settings: A Systematic Review. Healthcare, 5(4), 73. doi: 10.3390/healthcare504007

18. Risambessy, A., Swasto, B., Thoyib, A., & Astuti, E. S. (2012). The influence of transformational leadership style, motivation, burnout towards job satisfaction and employee performance. Journal of Basic and Applied Scientific Research, 2(9), 8833-8842.

19. Ashton, C., Duffie, D., & Millar, J. (2017). Conserving quality of life through community paramedics. Healthc Q, 20(2), 48-53.

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healthcare

Review

Importance of Leadership Style towards Quality of
Care Measures in Healthcare Settings:
A Systematic Review

Danae F. Sfantou 1, †, Aggelos Laliotis 2, † ID , Athina E. Patelarou 3, Dimitra Sifaki- Pistolla 4,
Michail Matalliotakis 5 ID and Evridiki Patelarou 6,*

1 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of
Athens Medical School, Athens 12462, Greece; danaes230@gmail.com

2 Department of Upper Gastrointestinal and Bariatric Surgery, St. Georges, NHS Foundation Hospitals,
London SE170QT, UK; laliotisac@gmail.com

3 Department of Anesthesiology, University Hospital of Heraklion, Crete 71500, Greece;
athina.patelarou@gmail.com

4 Clinic of Social and Family Medicine, School of Medicine, University of Crete, Crete 71500, Greece;
spdimi11@gmail.com

5 Department of Obstretics and Gynaecology, Venizeleio General Hospital, Heraklion, 71409, Greece;
mihalismat@hotmail.com

6 Florence Nightingale Faculty of Nursing and Midwifery, King’s College, London SE18WA, UK
* Correspondence: evridiki.patelarou@kcl.ac.uk; Tel.: +44-7596-434-780
† These authors have equally contributed to the manuscript.

Academic Editor: Sampath Parthasarathy
Received: 1 August 2017; Accepted: 25 September 2017; Published: 14 October 2017

Abstract: Effective leadership of healthcare professionals is critical for strengthening quality and
integration of care. This study aimed to assess whether there exist an association between different
leadership styles and healthcare quality measures. The search was performed in the Medline
(National Library of Medicine, PubMed interface) and EMBASE databases for the time period
2004–2015. The research question that guided this review was posed as: “Is there any relationship
between leadership style in healthcare settings and quality of care?” Eighteen articles were found
relevant to our research question. Leadership styles were found to be strongly correlated with quality
care and associated measures. Leadership was considered a core element for a well-coordinated and
integrated provision of care, both from the patients and healthcare professionals.

Keywords: leadership; leadership style; quality of care; nursing

1. Introduction

Nowadays, both evidence-based medicine and nursing are widely recognized as the tools for
establishing effective healthcare organizations of high productivity and quality of care. Management
and leadership of healthcare professionals is critical for strengthening quality and integration of care.
Leadership has been defined as the relationship between the individual/s who lead and those who
take the choice to follow, while it refers to the behaviour of directing and coordinating the activities of
a team or group of people towards a common goal [1,2]. There are many identified styles of leadership,
while six types appear to be more common: transformational, transactional, autocratic, laissez-faire,
task-oriented, and relationship-oriented leadership. Transformational leadership style is characterized
by creating relationships and motivation among staff members. Transformational leaders typically
have the ability to inspire confidence, staff respect and they communicate loyalty through a shared
vision, resulting in increased productivity, strengthen employee morale, and job satisfaction [3,4].

Healthcare 2017, 5, 73; doi:10.3390/healthcare5040073 www.mdpi.com/journal/healthcare

http://www.mdpi.com/journal/healthcare

http://www.mdpi.com

https://orcid.org/0000-0003-0681-2053

https://orcid.org/0000-0002-2967-184X

http://dx.doi.org/10.3390/healthcare5040073

http://www.mdpi.com/journal/healthcare

Healthcare 2017, 5, 73 2 of 17

In transactional leadership the leader acts as a manager of change, making exchanges with employees
that lead to an improvement in production [3]. An autocratic leadership style is considered ideal
in emergencies situation as the leader makes all decisions without taking into account the opinion
of staff. Moreover, mistakes are not tolerated within the blame put on individuals. In contrary,
the laissez-faire leadership style involves a leader who does not make decisions, staff acts without
direction or supervision but there is a hands-off approach resulting in rare changes [4]. Task-oriented
leadership style involves planning of work activities, clarification of roles within a team or a group
of people, objectives set as well as the continuing monitoring and performance of processes. Lastly,
relationship-oriented leadership style incorporates support, development and recognition [5].

Quality of care is a vital element for achieving high productivity levels within healthcare
organizations, and is defined as the degree to which the probability of achieving the expected health
outcomes is increased and in line with updated professional knowledge and skills within health
services [6]. The Institute of Medicine OM has described six characteristics of high-quality care
that must be: (1) safe, (2) effective, (3) reliable, (4) patient-centred, (5) efficient, and (6) equitable.
Measuring health outcomes is a core component of assessing quality of care. Quality measures
are: structure, process, outcome, and patient satisfaction [6]. According to the National Quality
Measures Clearing House (USA), a clinical outcome refers to the health state of a patient resulting
from healthcare. Measures on patient outcomes and satisfaction constitute: shorter patient length of
stay, hospital mortality level, health care-associated infections, failure to rescue ratio, restraint use,
medication errors, inadequate pain management, pressure ulcers rate, patient fall rate, falls with injury,
medical errors, and urinary tract infections [7].

There are numerous publications recognizing leadership style as a key element for quality of
healthcare. Effective leadership is among the most critical components that lead an organization
to effective and successful outcomes. Significant positive associations between effective styles of
leadership and high levels of patient satisfaction and reduction of adverse effects have been reported [8].
Furthermore, several studies have stressed the importance of leadership style for quality of healthcare
provision in nursing homes [9]. Transformational leadership is strongly related to the implementation
of effective management that establishes a culture of patient safety [10]. In addition, the literature
stresses that empowering leadership is related to patient outcomes by promoting greater nursing
expertise through increased staff stability, and reduced turnout [11]. Effective leadership has an
indirect impact on reducing mortality rates, by inspiring, retaining and supporting experienced staff.
Although there are many published studies that indicate the importance of leadership, few of these
studies have attempted to correlate a certain leadership style with patient outcomes and healthcare
quality indicators.

Therefore, the aim of this review was to identify the association between leadership styles with
healthcare quality measures.

2. Materials and Methods

This systematic review was designed and conducted in line with the published guidelines for
reporting systematic reviews and meta-analyses [12]. Systematic review of the existing literature on
leadership style and quality of healthcare provision was performed. The main review question was:
“Which is the relationship between styles of leadership in healthcare settings and quality of care?”
A systematic, comprehensive bibliographic search was carried out in the National Library of Medicine
(Medline) and EMBASE databases for the time period between 2004–2015 in the PubMed interface.
Search terms used were chosen from the USNML Institutes of Health list of Medical Subject Headings
(MeSH) for 2015. The included MeSH terms were: “Nurse Administrators”; “Nurse Executives”;
“Physician Executives”; “Leaders”; “Leadership”; “Managers”; “Management style”; “Leadership
style”; “Organizational style”; “Organizational culture/climate”; “Leadership Effectiveness”; “Quality
of healthcare”; “Patient outcome Assessment”; “Quality indicators, Healthcare”; “Healthcare quality,

Healthcare 2017, 5, 73 3 of 17

Access and Evaluation”; and “Quality Assurance, Healthcare”. References used by each identified
study were also checked and included in the study according to the eligibility criteria.

Five major inclusion criteria were adopted:

• Papers published in peer-reviewed journal
• Papers written in the English language
• Papers published from 2004 to 2015 (focus on more recent knowledge)
• Human epidemiological studies
• Studies used a quantitative methodology reporting the leadership style and healthcare

quality measures

Studies that did not meet the above criteria were excluded, while those that complied with the
inclusion criteria were listed and further reviewed.

Studies were evaluated and critically appraised (Aveyard critical appraisal tool) by two
independent reviewers. Literature screening (a three-stage approach-exclusion by reading the title, the
abstract, and the full text) and extraction of the data were conducted by two reviewers, independently.
In cases of uncertainty, a discussion was held among the members of the team to reach a common
consensus. Data were extracted systematically from each retrieved study, using a predesigned standard
data collection form (extraction table). The following information was extracted from each one of the
included studies (Table 1): authors, year of conduction, country, study design, subjects, population,
research purpose, leadership style definition, outcome definition, and main findings.

Healthcare 2017, 5, 73 4 of 17

Table 1. An overview of studies’ characteristics, outcome definitions and main findings.

Author et al. (year)
Main Study

Characteristics
Aim of the Study Leadership Style Definition Outcome Definition Main Findings

Al-Mailam (2004) [13] Kuwait,
cross-sectional study
Four public and private
hospitals
266 administrators and
physicians

To explore the
impact of leadership
styles on employee
perception of
leadership efficacy.

Two categories of administrators’
and physicians’ leadership style:

– Transformational leaders
– Transactional leaders

Leadership style
(Multifactor Leadership
Questionnaire)

Leadership style
(midpoint = 33,
average score)
Hospital director: 26.89
Department Head: 25.74
Leadership efficacy
[midpoint = 6.0
average score, (F-value)]
Both Medical director and Department Head = 4.44, (32.41 and
48.43)
Type of hospital and transformational leadership style
(average score, (SE))
public vs. private hospital
Hospital director: 29.48 (0.71) vs. 24.62 (0.73)
Department head: 27.28 (0.71) vs. 24.41 (0.67)

Armstrong et al. (2006)
[14]

Central Canada,
Small community hospital
40 staff nurses

To test a theoretical
model.

Structural empowerment
(Conditions of Work
Effectiveness Questionnaire-II)

Magnet hospital
characteristics—Practice
Environment
(Lake’s Practice Environment
Scale of the Nursing Work
Index, PES of NWI)

Safety climate
(The Safety Climate Survey)

Total Empowerment scale
[mean score (SD)]
17.1 (4.26) Cronbach α = 0.94
Total PES
[mean score(SD)]
2.5 (0.64) Cronbach α = 0.85
Safety Climate
[mean score(SD)]
3.53 (0.80) Cronbach α = 0.81
Empowerment and professional practice characteristics
[r (p-value)]
Nursing model of care 0.61 (<0.01) Management ability 0.52 (<0.01) Collaborative relationships 0.316 (<0.005) Empowerment and patient safety culture [r (p-value)] Patient safety culture 0.50 (<0.01) Support 0.51 (<0.01) Informal power 0.43 (<0.01) Opportunity 0.45 (<0.01)

Combined effect of magnet hospital characteristics on
patient safety culture and empowerment
46% of variance,
F = 13.32, dF = 1.31 p = 0.0001

Healthcare 2017, 5, 73 5 of 17

Table 1. Cont.

Author et al. (year)
Main Study
Characteristics
Aim of the Study Leadership Style Definition Outcome Definition Main Findings

Keroack et al. (2007) [15] US, 2003–2005
Exploratory investigation
79 Academic Medical
Centers
patient-level data
site visits

To identify
organizational
factors associated
with quality and
safety performance.

Hospitals’ leadership style:

– Authentic hands-on
leadership style

Patient safety
(Agency for health Care
Research and Quality,
AHRQ-preventable
complications, and Patient
Safety Indicators)
Mortality
(mortality rates bases on
AHRQ and inpatient quality
indicators, IQIs)
Effectiveness
(The Joint Commission
Hospital Core Measures)
Equity
(Measures)

Composite scores for quality and safety
CI 95% (median score %)
Group 1 vs. Group 2 vs. Group 3 vs. Group 4 vs. Group 5
67.18% vs. 62.36% vs. 60.22% vs. 58.68% vs. 56.05%

Factors associated with top performing organizations:

• Shared sense of purpose
• Authentic hands-on leadership style
• Accountability system of quality and safety
• Focus on results
• Culture collaboration

Kvist et al. (2007) [16] Finland
Kuopio University
Hospital
631 patients
690 nurses
76 managers
128 doctors

To investigate the
perception of the
quality of care and
the relationships
between
organizational
factors and quality
of care.

Quality of care
(measured by Humane Caring
Scale)
Organizational factors
(by using questionnaires)

Quality of care
(ratings)
Patients 1.51 to1.66
Nurses 1.81 to2.19
Managers 1.82 to 2.08
Organizational factors an Quality of care
– (coefficient of determination)
Nursing staff vs. managers vs. physicians0.462 vs. 0.548 vs.
0.337
– [standardized coefficient SC, (p-value)]
Nursing staff: work vs. values 0.248 (0.01) vs. 0.447 (0.001)
Managers: Work vs. leadership 0.472 (0.05) vs. 0.568 (0.05
Physicians: work vs. values
0.289 (0.05) vs. 0.539 (0.05)

Healthcare 2017, 5, 73 6 of 17

Table 1. Cont.
Author et al. (year)
Main Study
Characteristics
Aim of the Study Leadership Style Definition Outcome Definition Main Findings

Vogus, Sutcliffe (2007) [17] US, 2003–2004
cross-sectiona
l1033 RNs
78 nursing managers
78 care units

To examine the
benefits of bundling
safety organizing
with leadership and
design factors on
reported medication
errors.

Safety organizing
(Safety organizing Scale)
Trust in manager
(2 survey items assessing
perceptions for nurse manager)
Use of care pathways
(Seven-point Likert Scale,
single survey item)

Reported Medications
errors
(number of errors reported to a
unit’s incident reporting
system)

Medications errors
(mean, SD) 12.04, 11.31
Safety organizing and trusted leadership
(β, coefficient, p-value)
−0.60, 0.18, p < 0.001 Safety organizing and care pathways −0.82, 0.25, p < 0.001

Casida, Pinto-Zipp (2008)
[18]

New Jersey, US, 2006
Four acute care hospitals
37 Nurse Managers
278 staff nurses

To explore the
relationship
between nursing
leadership styles
and organizational
culture.

Three categories of nurse
managers’ leadership style:

– Transformational leaders
– Transactional leaders
– Non-transactional

laissez-faire leaders

Leadership style
(Multifactor Leadership
Questionnaire)

Nursing unit
Organizational culture
(the Denison’s Organizational
Culture Survey)

Leadership style
[MLQ scores, mean (SD)]
Transformational vs. transactional vs. laissez-faire
2.8 (0.83) vs. 2.1 (0.47) vs. 0.83 (0.90)
NMs’ leadership style and organizational culture
(r, p-value)
Transformational vs. transactional vs. laissez-faire
0.60 (p = 0.00) vs.0.16 p = 0.006) vs.−0.34 (p = 0.000)

Raup (2008) [19] US
15 academic health centers
15 managers
15 staff nurses

To explore the role
of leadership styles
used by nurse
managers in nursing
turnover and patient
satisfaction.

Two categories of ED nurse
managers’ leadership style:

– Transformational leadersNon
– Non-transformational leaders

Leadership style
(Multifactor Leadership
Questionnaire, MLQ)
Nurse staff turnover and
patient satisfaction
(managers’ data for nurse
turnover and patient safety
scores)

Leadership style
(% ED nurse managers)
transformational vs. Non-transformational
80% vs. 20%
Nurse staff turnover and patient satisfaction
[impact of leadership style:
Fisher’s exact test = 0.569]
Mean staff nurse turnover (%)
transformational vs. Non-transformational 13% vs. 29%
Mean ED overall patient satisfaction (%)
transformational vs. Non-transformational76.68% vs. 76.50%

Healthcare 2017, 5, 73 7 of 17

Table 1. Cont.
Author et al. (year)
Main Study
Characteristics
Aim of the Study Leadership Style Definition Outcome Definition Main Findings

McCutcheon et al. (2009)
[20]

Canada
Correlation survey
Seven hospitals
51 units
41 nurse managers
717 nurses
680 patients

To assess the
relationship
between leadership
style, nurses’ job
satisfaction, span of
control, and patient
satisfaction.

Four categories of managers’
leadership style:

– Transformational leaders
– Transactional leaders
– Management by exception
– Laissez-faire

Nurses’ Job Satisfaction
(measured by
McCloskey-Mueller
Satisfaction Scale
Patient Satisfaction
(measured by the Patient
Judgments of Hospital
Quality Questionnaire)

Nurses’ Job Satisfaction
(Mean) 3.2
Patient Satisfaction
(mean) 2.16 (moderate satisfaction)
JS and leadership style
Transformational vs. transactional vs. management by
exception vs. laissez-faire (Beta)
0.20 vs. 0.12 vs. −0.08 vs. 0.02
Span of control and leadership style on JS
Transformational vs. transactional vs. management by
exception vs. laissez-faire [coefficient, (p-value)]
−0.0024 (<0.01) vs. −0.0015 (<0.05) vs. 0.0026 (<0.01) vs. 0.0014 (<0.05) Span of control and leadership style on patient satisfaction [coefficient, (p-value)] Transformational vs. transactional vs. management by exception vs. laissez-faire −0079(<0.05) vs. −0070 vs. −0103 vs. 0.0045

Singer et al. (2009) [21] US, 2004–2005
92 hospitals
senior managers,
physicians, hospital
workers
questionnaires
18361 safety climate
surveys
5637 organizational
culture surveys

To assess the aspects
of general
organizational
culture that are
related to hospital
patient safety
climate.

Safety climate
(Patient Safety Climate in
Healthcare Organization)
Organizational culture
(Competing Values
Framework)

Organisational culture
(average score)
hierarchical organizational culture vs. entrepreneurial culture
31.6 points vs. 15.7points
Safety climate
(% PPR-percent problematic response) (higher PPR relates to
lower level of safety climate)
17.1% PPR
Highest safety climate hospitals vs. lowest safety climate
hospitals (mean PPR, p = 0.000) 11.5 vs. 24.6
Relationship of organizational characteristics with patient
safety climate
[overall average PPR (SD) p < 0.05] group culture vs. entrepreneurial culture vs. hierarchical culture vs. production-oriented culture −0.241 (0.011) vs.−0.279 (0.0022) vs. 0.300 (0.011) vs. 0.0666 (0.017) Organizational culture and safety climate [mean (SD] high vs. low safety climate group culture: 40.1 (6.7) vs. 26.9 (7.8) entrepreneurial: 15.3 (2.31) vs. 13.9 (0.9) production-oriented: 20.20 (2.1) vs. 22.4 (2.1) hierarchical: 24.6 (2.8) vs. 36.7 (6.2)

Healthcare 2017, 5, 73 8 of 17

Table 1. Cont.
Author et al. (year)
Main Study
Characteristics
Aim of the Study Leadership Style Definition Outcome Definition Main Findings

Alahmadi (2010) [22] Saudi Arabia,
13 general hospitals
223 health professions
(nurses, technicians,
managers, medical staff)

To assess whether
organisation culture
supports patient
safety.

Patient safety culture
(Hospital Survey on Patient
Safety Culture questionnaire)

Patient safety
Excellent or very good vs. acceptable vs. failing or poor (%)
60% vs. 33% vs. 7%
Determinants of overall patient safety score(Standardised
coefficient B)
Organisational learning/continuous improvement: 0.128
Management role: 0.216
Communication and feedback about errors: 0.215
Teamwork: 0.160

Armellino et al. (2010)
[23]

US
descriptive correlation
study
Adult Critical Care Unit
(ACCU) tertiary hospital
102 Registered Nurses

To explore the
association between
structural
empowerment and
patient safety
culture among
nurses.

Structural empowerment,
SE
(Conditions of Workplace
Effectiveness Questionnaire)

Patient safety climate
(Hospital Survey on Patient
Safety Culture)

Total structural empowerment, SE
(CWEQ-II, mean score)
20.55 (moderate), Cronbach’s α = 0.89
Moderate SE vs. low level of SE vs. high level of SE (%)
79.2% vs. 1.98% vs. 18.91%
Structural empowerment and patient safety climate (PSC)

– Total CWEQ-II score and overall perception of
safety(Pearson’s correlation coefficient)0.32 p < 0.05

– Total CWEQ-II empowerment score and HSOPC safety
grade(total SE score)

Grade A vs. Grade B vs. Grade C vs. Grade D22.667 vs.
20.987 vs. 19.763 vs. 15.889

Cummings et al. (2010)
[24]

Canada, 1998–1999
Secondary analysis of
data
90 hospitals
21,570 patients
5228 nurses

To explore the
association of the
role of hospital
nursing leadership
styles with 30-day
mortality.

Five categories of hospitals’
leadership style:

– high resonant
– moderately resonant
– mixed
– moderately dissonant
– high dissonant

30-day mortality Hospital Nursing leadership styles and 30-day mortality
High dissonant vs. moderately dissonant vs. mixed type vs.
moderately resonant vs. high resonant (%)

4.3 vs. 8.8 vs. 8.1 vs. 7.4 vs. 5.2

High dissonant vs. moderately dissonant vs. mixed type vs.
moderately resonant vs. high resonant Beta (SE)

Ref vs.−0.64 (0.24) * vs. 0.05 (0.11) vs.−0.08 (0.10) vs.−0.40
(0.19) *

High dissonant vs. moderately dissonant vs. mixed type vs.
moderately resonant vs. high resonant aOR 95% CI

Ref vs. 0.86 (0.56–1.31) vs. 1.10 (0.96–1.27) vs. 0.90 (0.77–1.04)
vs. 0.77 (0.59–1.01)

Healthcare 2017, 5, 73 9 of 17

Table 1. Cont.
Author et al. (year)
Main Study
Characteristics
Aim of the Study Leadership Style Definition Outcome Definition Main Findings

Ginsburg et al. (2010) [25] Canada, 2006
Two cross-sectional
surveys
49 general acute care
hospitals
54 patient safety officers
(PSOs)
282 patient care managers
(PCMs)
PSOs and PCMs
questionnaires

To explore
organizational
leadership towards
patient safety and its
relationship with
five types of
learning from
patient safety
events.

Two categories of organizational
leadership style:

– Informal organizational
– Formal organizational

Leadership style
(PCM questionnaire)
Learning from PSEs
(four types of
PSE-minor/moderate/major
events/major near-miss)

Learning from PSEs
[Mean (SD)]
major event analysis 3.63 (0.56)
major event dissemination/communication 2.86 (0.80)
moderate event learning 3.03 (0.76)
minor events learning 2.53 (0.67)
major near-miss events learning 3.03 (0.75)formal
organizational leadership 3.90 (0.44)
informal organizational leadership 2.34 (1.28)
Learning from Near-miss Events
(β, p-value)
hospital size −0.339 p < 0.10 formal leadership style 0.467 p < 0.05 Learning from Major events dissemination/communication (β, p-value) hospital size and formal leadership style −1.106, p < 0.001

Purdy et al. (2010) [26] Canada,
Cross-sectional study
21 hospitals (61 medical
and surgery units)
697 nurses
1005 patients

To assess the
relationship of
nurses’ perceptions
on their work
environment and
quality outcomes.

Work environment
(Conditions of Workplace
Effectiveness Questionnaire,
and Work Group
Characteristics Measure)
Patient care
quality/patient satisfaction
(Nursing Care Quality
Questionnaire and The
Therapeutic Self-care
Questionnaire-Acute Care
Version)

Work environment and patient outcomes
[χ2 = 21.074 df = 10]
Work unit
(β, p-value)
structure empowerment and group processes 0.64 p < 0.001 group processes and nurse-assessed quality 0.61 p < 0.001 group processes and falls −0.19 p < 0.05 group processes and nurse-assessed risk −0.17 p < 0.05 Individual (β, p-value) psychological empowerment and empowerment behavior 0.47 p < 0.001 psychological empowerment and job satisfaction 0.39 p < 0.001 psychological empowerment and nurse assessed quality of care 0.22 p < 0.001

Squires et al.
(2010) [27]

Ontario, Canada, 2008
cross-sectiona
l267 nurses

To test a model of
examining
relationships among
leadership,
interactional justice,
work environment,
safety climate
quality of the
nursing and patient
and nurse safety.

Nurse managers leadership:

– Resonant Leadership

Leadership (measured by
Resonant leadership Scale)
Nursing work
environment
(by using Perceived nursing
work environment)
Safety climate
(measured by Safety Climate
Survey)

Final model
χ2 = 217.6(138) p < 0.001 -resonant leadership and leader-nurse relationship (standardized coefficient) 0.52 nurse leader-nurse relationship and safety climate (standardized coefficient) 0.53 work environment and emotional exhaustion (standardized coefficient) −0.51 safety climate and medication errors (standardized coefficient) −0.22

Healthcare 2017, 5, 73 10 of 17

Table 1. Cont.
Author et al. (year)
Main Study
Characteristics
Aim of the Study Leadership Style Definition Outcome Definition Main Findings

Castle, Decker
(2011) [28]

US, 2008
3867 NHAs (Nursing
Home Administrator)
3867 DONs (Director of
Nursing)

To assess the
relationship of
leadership style and
quality of care.

Four groups of leaders:

– Consensus manager
– Consultative autocrat
– Shareholder manager
– Autocrat

Leadership style
(Bonoma-Slevin leadership
model)

Quality of care
(Nursing Home Compare
Quality Measures and 5-Star
Rating Scores)

Leadership style
Consensus manager vs. consultative vs. shareholder manager
vs. autocrat:
NHA: 33% vs. 22% vs.19% vs. 26%
DON: 30% vs. 20% vs.25% vs. 25%
Leadership and quality of care
[Incident-rate ratio (SE), p-value]
NHA/DON both Consensus Managers:
Percent physical restraint use: 0.97 (0.43), p < 0.05 Percent with moderate to severe pain: 0.51 (0.21), p < 0.01 Percent high-risk residents with pressure ulcers: 0.62 (0.24), p < 0.05 Percent had a catheter inserted and left in bladder: 0.79 (0.19), p < 0.001

NHA/DON both Consensus Managers:
(Five-star quality measure score, squares regression)
4.02 p < 0.01

Havig et al.
(2011) [9]

Norway,
Cross-sectional study
40 wards of nursing
homes
414 employees
13 nursing home
directors40 wards
managers
444 staff questionnaires
378 relatives
900 h of field observation

To assess the
relationship
between ward
leaders’ task—and
leadership styles, on
measures of quality
of care.

2 categories of hospitals’
leadership style:

– Task-oriented leaders
– Relationship-oriented leaders

Quality of care
(The national regulation for
quality of care in nursing
homes and home care)
Staffing
Care level

Leadership style and quality of care
[coefficient (p-value)
Task-oriented leadership style
Relatives vs. staff vs. field observations
0.36 (0.02) vs. 0.63 (>0.01) vs. 0.28 (0.12)
Relationship-oriented leadership style
0.12 (0.19) vs. 0.01 (0.91) vs. 0.10 (0.37)
Staffing and quality of care
[coefficient (p-value)Total staffing level
Relatives vs. staff vs. field observations
−0.95 (0.31) vs. 0.10 (0.90) vs. 1.17 (0.30)
Ratio of RNs
0.32 (0.66) vs. 0.52 (0.42) vs. 0.20 (0.83)
Ratio of unlicensed staff
−2.05 (>0.01 vs. −0.80 (0.22) vs. −2.59 (>0.01)
Care level
[coefficient (p-value)
Relatives vs. staff vs. field observations
−0.20 (>0.01) vs. −0.11 (>0.01) vs. −0.11 (0.02)

Healthcare 2017, 5, 73 11 of 17

Table 1. Cont.
Author et al. (year)
Main Study
Characteristics
Aim of the Study Leadership Style Definition Outcome Definition Main Findings

Kvist et al.
(2013) [29]

Finland, 2008–2009
Cross-sectional,
descriptive quantitative
design
Four hospitals
2566 patients
Nursing staff

To examine nurses’
and patients’
perceptions of the
Magnet model
components of
transformational
leadership and
quality outcomes.

One category of hospitals’
leadership style:

– Transformational
leadership style

Transformational
Leadership style
(transformational leadership
scale)
Job satisfaction
(The Kuopio University
Hospital Job Satisfaction)
Patient Safety Culture
(The Hospital Survey on
Patient Safety Culture)
Patient Satisfaction
(Revised Humane Caring
Scale)

Transformational Leadership style
Support for professional development by nurse managers
(mean, SD) 3.66, 0.96
Patient Safety Culture
(mean, SD)Teamwork within units 3.64, 0.69
Supervision 3.60, 0.80
Communication openness 3.57, 0.68
Patient Satisfaction
(mean, SD, p-value)
Professional practice 4.49, 0.67
Human resources 3.80, 1.13
PS average score
(mean, SD) 4.18, 0.69
Total JS
(mean, SD) 3.59, 0.62
Transformational leadership
(mean, SD) 3.47, 0.81
Patient Safety Culture
(mean, SD) 3.3, 0.47

Healthcare 2017, 5, 73 12 of 17

3. Results

3.1. Bibliographic Search

A total of 2824 records were retrieved through our searches in Medline and EMBASE databases.
Following reading the titles and abstracts of the retrieved records 212 remained for further evaluation.
Another 194 articles were excluded after reading the full article. Figure 1 shows the exact sequence and
process of study identification, selection and exclusion in each step of the search. Finally, 18 studies
were considered to be appropriate for answering our primary research question.

Healthcare 2017, 5, 73 10 of 14

3.

Results

3.1. Bibliographic Search

A total of 2824 records were retrieved through our searches in Medline and EMBASE databases.

Following reading the titles and abstracts of the retrieved records 212 remained for further

evaluation. Another 194 articles were excluded after reading the full article. Figure 1 shows the exact

sequence and process of study identification, selection and exclusion in each step of the search.

Finally, 18 studies were considered to be appropriate for answering our primary research question.

Figure 1. Prisma flowchart.

3.2. Overview of the Included Studies

Among 18 included studies, seven were conducted in the USA, six in Canada, two in Finland,

one in Saudi Arabia, one in Kuwait, and one in Norway. Among the relevant studies, 14 were

cross-sectional, two were descriptive correlation studies, one was a secondary analysis of data, and

one was an exploratory investigation. Diverse care settings were represented in the studies.

Identified settings included: hospitals/healthcare settings (n = 16), acute and critical care units (n = 1),

and oncology settings (n = 1). In addition, study samples consisted exclusively of employees (n = 16),

or combination of employees and managers (n = 2). Patient safety climate, patient satisfaction,

mortality, and quality of care were the main outcomes of interest. Leadership was assessed in these

studies according to leadership styles, behaviors, perceptions, and practices. The most commonly

Figure 1. Prisma flowchart.

3.2. Overview of the Included Studies

Among 18 included studies, seven were conducted in the USA, six in Canada, two in Finland,
one in Saudi Arabia, one in Kuwait, and one in Norway. Among the relevant studies, 14 were
cross-sectional, two were descriptive correlation studies, one was a secondary analysis of data,
and one was an exploratory investigation. Diverse care settings were represented in the studies.
Identified settings included: hospitals/healthcare settings (n = 16), acute and critical care units
(n = 1), and oncology settings (n = 1). In addition, study samples consisted exclusively of employees
(n = 16), or combination of employees and managers (n = 2). Patient safety climate, patient satisfaction,
mortality, and quality of care were the main outcomes of interest. Leadership was assessed in these

Healthcare 2017, 5, 73 13 of 17

studies according to leadership styles, behaviors, perceptions, and practices. The most commonly used
tool to measure leadership was the Multifactor Leadership Questionnaire, MLQ, (n = 7). The variety
of the quality measures and different definitions/scales used among a limited number of included
studies did not allow the performance of a meta-analysis of the retrieved findings.

3.3. Leadership Style and Patients Outcomes

Improved quality of healthcare services (moderate-severe pain, physical restraint use, high-risk
residents having pressure ulcers, catheter in bladder) was reported for consensus manager leadership
style [28]. Resonant leadership influenced the quality of safety climate which, in turn, impacted on
medication errors [27]. Resonant leadership style was related to lower 30-day mortality and presented
a strong association of 28% lower probability of 30-day mortality comparing with high-dissonant
(14% lower) followed by hospitals with mixed leadership styles [24]. The task-oriented leadership
style was found to relate to higher levels of quality of care based on the assessment made by relatives
and staff [9]. Furthermore, formal leadership style was positively associated with learning from minor
and moderate patient safety events, while informal leadership presented no effect [25]. Patients were
more satisfied when the manager followed a transactional leadership style [24]. However, Raup found
that there was no association between leadership style and patient satisfaction [19].

3.4. Organizational Culture and Quality of Care

Important relationships between workplace enforcement and practice environmental conditions
for staff nurses and patient safety were observed [14]. Authentic hands-on leadership style, behaviors
and organizational practices of distinctive leadership were associated with significant differences
in patient level measure of quality and safety; such as mortality patterns, patient safety, equity and
effectiveness in care [15]. Transformational leadership was found to positively relate with effective
nursing unit organization culture, while transactional leadership had a weak relationship. In addition,
laissez-faire leadership was negatively related to nursing unit organization culture [18]. Findings
confirmed that the higher total structural empowerment score was correlated to a higher safety
level and empowering workplaces contributed to positive effects on nursing quality of care [23,26].
Higher entrepreneurial culture was also related to higher levels of safety climate for the patient [30].
Alahmadi also found that the variables that contributed to patient safety score included management
role, organization learning, continuous improvement, communication, teamwork, and feedback about
errors [22]. Singer et al. found that higher group culture was associated with higher safety climate
overall but more hierarchical culture was correlated with lower safety climate suggesting that general
organizational culture is important to organizations’ climate of safety [21]. Role ambiguity and role
conflict on the units were found to relate to higher turnover rates for nurses. The increased likelihood
of medical error was related to the higher level of role ambiguity and a higher turnover rate. Finally,
lack of employer care and team support were the most common reasons for leaving [31].

4. Discussion

Effective leadership in health services has already been extensively studied in the literature,
especially during the last decades [32]. Several societal challenges have revealed the urgent need for
effective leadership styles in health and social services. Nevertheless, studies that use quantitative data
or assess the impact of leadership in health care quality measures are neglected, while most studies
have adopted a qualitative approach [33]. The present literature review attempted to fill this gap,
while it managed to identify the most recent publications to assess the correlation between leadership
styles with healthcare quality measures.

Among the main findings, correlation of leadership with quality care and a wide range of patient
outcomes (e.g., 30-day mortality, safety, injuries, satisfaction, physical restraint use, pain, etc.) were
stressed in most of the identified articles [9,24,27,28]. Therefore, leadership is considered a core
element for a well-coordinated and integrated provision of care, both from the patients and healthcare

Healthcare 2017, 5, 73 14 of 17

professionals. It is essential regardless of where care is delivered (e.g., clinics or inpatient units,
long-term care units, or home care facilities), especially for those who are directly involved with
patients for long periods of time [34].

Additionally, effects of leadership style on patient outcomes were evident in the aforementioned
findings. Other studies [35] agree with our main findings and stress the theoretical interactions of
effective leadership and patient outcome as follow; effective leadership fosters a high-quality work
environment leading to positive safety climate that assures positive patient outcomes. Failure of
leadership to create a quality work place ultimately harms patients [29,35]. Most of these studies are
focusing on nursing leadership. Particularly, as also reported by the current study, transformational
and resonant leadership styles are associated with lower patient mortality, while relational and
task-oriented leadership are significantly related to higher patient satisfaction [35–37]. Furthermore,
increased patient satisfaction in acute care and homecare settings has been found to be closely related
to transformational, transactional, and collaborative leadership [36,37]. Overall, the vast majority
of studies assessing patient outcomes in the literature, have reported adverse outcomes defined as
unintentional injuries or complications associated with clinical management, rather than the patient’s
primary condition, resulting in death, disability, or extended stay in hospital [17,37].

Furthermore, leadership has been recognized as a major indicator for developing qualitative
organizational culture and effective performance in health care provision [14]. Similarly to our study,
other studies that used primary quantitative data revealed a strong correlation of leadership and
safety, effectiveness, and equity in care. For instance, transformational leadership increases nursing
unit organization culture and structural empowerment [18]. This has an impact on organizational
commitment for nurses and in return higher levels of job satisfaction, higher productivity, nursing
retention, patient safety, and overall safety climate, and positive health outcomes [18,23,38]. In addition,
safety climate was among the main findings of our study. As supported by the literature [38], a safety
climate connected to transformational leadership style is strongly linked to improved process quality,
high organization culture and positive patient outcomes. Therefore, safety climate is directly associated
with improved patient safety outcomes and the overall quality of care.

The literature has identified the significance of leadership styles and practices on patient outcomes,
health care workforce and organizational culture. Setting effective leadership as a priority in
health care units is expected to enhance a variety of measurable indicators, even in fragmented
health systems [39]. Nowadays, more and more regional and national health systems tend to
undergo structural changes and redesign their functions and priorities in order to face modern
societal, economic, and health challenges and needs [17]. Medical leadership in decision-making is
a key component in order to develop a successful and qualitative priority setting process in health
care. Most importantly, engagement of non-medical clinical leaders, such as nursing leadership,
is considered to ensure the legitimacy and validity of priority setting [40]. As shown in the present
study, the leadership styles that proved to be more effective and promoted positive outcomes
were those that conceptualize management as a collaborative, multifaceted, and dynamic process
(e.g., transformational, employee-oriented leadership).

Future research has to focus on the development, feasibility and implementation of robust
leadership styles models in diverse health care settings. These studies should include multidisciplinary
professional teams, strengthen the role of nurses and other health care professionals, explore additional
quality of life and healthy ageing indicators (both for professionals and patients), and address
organizational parameters and individual wishes, preferences, and expectations towards quality
in health care [17,37,40–44].

5. Conclusions

Leadership styles play an integral role in enhancing quality measures in health care and nursing.
Impact on health-related outcomes differs according to the different leadership styles, while they
may broaden or close the existing gap in health care. Addressing the leadership gap in health

Healthcare 2017, 5, 73 15 of 17

care in an evolving and challenging environment constitutes the current and future goal of all
societies. Health care organizations need to ensure technical and professional expertise, build capacity,
and organizational culture, and balance leadership priorities and existing skills in order to improve
quality indicators in health care and move a step forward. Interpretation of the current review’s
outcomes and translation of the main messages into implementation practices in health care and
nursing settings is strongly suggested.

Acknowledgments: Open access for this article was funded by King’s College London.

Author Contributions: A.P. and E.P. conceived the idea, wrote the review protocol and performed the search.
D.S.P. and M.M. selected and reviewed the papers and also drafted the Table. D.S. and A.L. wrote the paper.
All authors have read and approved the content of the paper.

Conflicts of Interest: The authors declare no conflict of interest.

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© 2017 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

http://dx.doi.org/10.1503/cmaj.1040498

http://dx.doi.org/10.1111/jonm.12116

http://www.ncbi.nlm.nih.gov/pubmed/23865924

http://dx.doi.org/10.1097/00004010-199622000-00006

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• Introduction
• Materials and Methods

Results
Bibliographic Search
Overview of the Included Studies
Leadership Style and Patients Outcomes
Organizational Culture and Quality of Care

• Discussion
• Conclusions

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/283987859

Leadership in Street-Level Bureaucracy: An Exploratory Study

of Supervisor-Worker Interactions in Emergency Medical

Services

Article  in  International Review of Public Administration · April 2013

DOI: 10.1080/12294659.2013.1080523

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© International Review of Public Administration
2013, Vol. 18, No. 1

7

LEADERSHIP IN STREET-LEVEL BUREAUCRACY:
AN EXPLORATORY STUDY OF SUPERVISOR-
WORKER INTERACTIONS IN EMERGENCY

MEDICAL SERVICES

ALEXANDER C. HENDERSON
Long Island University, USA

SANJAY K. PANDEY
Rutgers University-Newark, USA

Street-level bureaucrats operate in a world relatively free of supervision,
exercising discretionary abilities often without the presence of formal
authority figures or managers. Although wide latitude in decision making is
a norm of frontline work, leaders may occasionally be present to supervise
service provision. This exploratory research employs narrative inquiry to
examine the interactions of street-level personnel and formal authority
figures during service provision in emergency medical services. Results
indicate that occasions for compliance and disregard for managerial
directives are manifest. Compliant behavior was evident when patient
clinical needs were relatively clear and the effects of the directives were
reasonably consistent with the paramedic s preconceived notions of
appropriate action. Deviation from managerial directives was apparent
when patient s positive outcomes were dependent on ignoring orders.
Contributions to theory and practice, as well as avenues for future research
are discussed.

Key Words: emergency medical services, street-level bureaucracy,
leadership

INTRODUCTION

The demand for emergency medical services (EMS) in the United States has
increased steadily since the advent of formal systems of prehospital care in the mid-
twentieth century, with more than 36 million calls for service and 28 million patients
transported in 2009 (Federal Interagency Committee on EMS, 2011). This volume of
service interactions, when considered concomitantly with the intricacies and complexity
of providing human services and the magnitude of the consequences of individual and
organizational performance in EMS, calls for a need to identify and understand these
interactions in greater detail and specificity.

Individuals engaged in EMS provision specifically tasked with treating and
transporting patients to definitive care can be conceptualized as street-level bureaucrats
(Lipsky, 1980). Past research on street-level bureaucracy has focused on several
occupational areas, including law enforcement, nursing, welfare eligibility workers, and
teachers (Isett, Morrissey, and Topping, 2006; Maynard-Moody and Musheno, 2003;
Riccucci, 2005), on the influence of management in frontline decision making (May and
Winter, 2007; Riccucci, 2005), and on concepts of leadership in street-level services
(Vinzant and Crothers, 1994, 1996, 1998). These studies have established a foundation of
knowledge that makes clear the importance of street-level workers in the implementation
of policy, highlights the role of discretion and legitimacy in this process, and examines
the relationship between frontline workers and direct supervisors. Given the substantial
impact of frontline workers on actual provision of services, it is important to advance
understanding of ways in which leadership and supervision can make a difference.

As with other street-level professions, EMS providers generally work in a context
relatively free of formal supervision, are exposed to substantial situational complexity
and contingencies, and must engage in discretionary decision-making processes with
limited assistance from formal authority figures. In select cases, organizational
supervisors or managers may be present to supervise direct service provision, and
instances of supervisory input may result in general agreement, signaling appropriateness
of rule application or adherence to professional or organizational norms, or may serve to
challenge the relative autonomy of street-level EMS providers.

Considering the latter, a question naturally becomes evident: What factors may spur
acquiescence with, or deviation from, supervisory directives in cases of disagreement or
conflict? This exploratory research examines two cases of conflict and determines
subjectively important factors that frontline EMS workers note as central in their
decisions to abide by or deviate from directives. A grounded theory approach is used to
examine text generated by semi-structured interviews of frontline paramedics discussing
accounts of challenging or complex incidents. We first review pertinent literature on
street-level bureaucracy, management of frontline employees, and emergency medical
services. Next, we outline the research design and methods used to present and discuss

8 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1
Supervisor-Worker Interactions in Emergency Medical Services

two narratives of street-level EMS care. We acknowledge the limitations of the study and
offer concluding thoughts, focusing on contributions to theory and practice and directions
for future research.

LEADERSHIP IN STREET-LEVEL WORK

Two major streams of research have previously addressed leadership in direct service
provision and are especially relevant to this question. While the first focuses on how
street-level service providers may exercise discretion in a rule-saturated environment, the
second perspective examines the prospects for leaders to influence street-level work.

Street-Level Public Service

Lipsky s (1980) seminal work on street-level bureaucracy defined and brought to the
fore concepts of frontline public service. Two defining characteristics of street-level
occupations were notable in these early discussions: face-to-face interactions with clients
and the ability to exercise discretion (Handler, 1986; Lipsky, 1980). Street-level
bureaucrats follow complex rule sets in uncertain and time-bound situations, all within a
context of potentially ambiguous organizational goals (Keiser, 1999). Frontline personnel
are critical to the success of public programs as they occupy the final step in the policy
implementation process (Lipsky, 1980; Riccucci, 2005; Maynard-Moody and Musheno,
2003), and their actions in many cases have a direct impact on important quality-of-life
issues for clients and, when considered cumulatively, on the outcomes of these public
programs (Bovens and Zouridis, 2002; Keiser, 1999; Riccucci, 2005).

The concept of administrative discretion and constraints on behavior take center stage
in this discussion of frontline workers. Hupe and Hill (2007) noted that as rules specify
the duties and obligations of officials, discretion allows them freedom of action (280
281). When rules are incomplete, inappropriate, or vague, other sources of influence may
be crucial in shaping the discretionary behavior (Handler, 1986; Vinzant and Crothers,
1998), including social, professional, and organizational norms, beliefs, and values
(Dworkin, 1977; Hupe and Hill, 2003; Scott, 1997). Street-level service provision, then,
lies at the intersection of rules, cultural expectations, and situational factors, thereby
posing a flexibility versus uniformity dilemma (Loyens and Maesschalck, 2010: 67).

Research on frontline positions has found empirical support for many of these
assertions. Rules are influential in shaping behavior, as are organizational and
occupational culture (Isett, Morrissey, and Topping, 2006; Kelly, 1994; Sandfort, 2000;
Riccucci, 2005), and extraorganizational sources of influence, including direct and
indirect relationships with political principals (Gilboy, 1992; May and Winter, 2007).

April 2013 Alexander C. Henderson & Sanjay K. Pandey 9

Management and Leadership in Street-Level Work

Managerial influence on street-level bureaucrats has been examined with varying
results across different occupations and organizational settings (May and Winter, 2007;
Riccucci, 2005). Riccucci (2005) noted a number of distinct methods that managers may
use to foster change at the frontlines of welfare agencies, including training, engaging
workers in decisions about processes, providing feedback, and use of administrative
interventions to encourage or discourage specific behavior (87 89). However, because
managers are in many cases not present for service interactions in bottom-heavy street-
level services, these activities tend to occur before or after a service interaction. In those
cases in which a manager is present or engaged in decision making, the manager may
serve to establish or reify what constitutes appropriate behavior.

May and Winter (2007), in a study of street-level bureaucrats implementing
employment assistance reforms in Denmark, found that higher-level officials can have a
substantive impact on the manner in which workers understand and implement policy
(469). Although the magnitude of supervisory influence was somewhat weak, this
finding serves to link the influence of superiors on street-level bureaucrats with their
espoused views on policy. Attention to a specific policy by higher-level officials may
promote understanding or engagement with a policy, and managers who are increasingly
persuasive may exert more influence in adherence to policies.

A body of literature specifically examining street-level leadership has emerged,
focusing on the leader-like qualities of street-level workers themselves (Vinzant and
Crothers, 1996: 464). Frontline workers may be able to exercise substantial discretion
over outcomes (reflecting a transformational leadership style), discretionary decisions
about processes (reflecting a transactional or situational leadership style), or discretion
over both (reflecting a combined style) (Vinzant and Crothers, 1998: 91 92). In each of
their studies of police behavior, Vinzant and Crothers (1994, 1996, 1998) found evidence
of the situationally contingent exercise of transactional and transformational leadership
styles. Discretionary decisions about both process and outcomes were shaped by
leadership from colleagues not identified as formal managers or supervisors.

Emergency Medical Services

EMS has evolved into a core public service over the last several decades (IOM, 2007:
1), and research examining the field has generally fallen into one of three categories of
inquiry: clinical, educational, or systems level (NHTSA, 2001). Clinical studies examine
the therapeutic and medicinal aspects of EMS, studying topics such as the efficacy of
medications (McEachin, McDermott, and Swor, 2002; Reed, Synder, and Hogue, 2002).
Educational research has examined the efficacy of formal training (LeBlanc et al., 2005)
and experiential learning in EMS (David and Brachet, 2009). Systems-level

10 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1
Supervisor-Worker Interactions in Emergency Medical Services

investigations have studied the process of predicting call volume (Brown et al., 2007;
Setzler, Saydam, and Park, 2009) and the effects of response time and service level on
patient outcomes (Nichol et al., 1996; Pons and Markovchick, 2002). These studies
contribute to our understanding of the service and may have a tangible impact on street-
level EMS providers, yet they leave important gaps in knowledge that cut across
boundaries. Thus, they fail to examine the full nature of the complex interactions among
EMS personnel and patients.

METHODS

Empirical research into the unique nature of street-level bureaucrats has employed
qualitative methods (Gilboy, 1992; Maynard-Moody and Musheno, 2003; Newman,
Guy, and Mastracci, 2009; Sandfort, 2000; Vinzant and Crothers, 1998), mixed methods
(Oberfield, 2010; Riccucci, 2005), and quantitative experimental studies (Scott, 1997).
This paper serves as a preliminary investigation of influence and the exercise of
discretion in frontline leader-worker interactions, topics that are both inherently
subjective. Accordingly, an interpretive methodological foundation is appropriate for this
study.

This exploratory research uses a narrative analysis to capture several interrelated,
multifaceted, and relatively unexamined concepts as they emerge in the tangible actions
of frontline EMS providers (Yin, 1994). The unit of analysis for the study is the narrative
of a street-level EMS worker caring for a patient amid physical, social, and clinical
contingencies. Klein, Calderwood, and Macgregor (1989) characterize such settings as
“naturalistic ones [with] high time pressure, high information content, and changing
conditions” (462). Our use of stories is similar to Klein (1998), who makes the astute
observation that “stories […] contain many different lessons and are useful as a form of
vicarious experience for people who did not witness the incident” (179).

Participating Individuals and Organizations

EMS agencies were selected from a single state, Pennsylvania, in order to keep the
political and regulatory context constant across organizations. Pennsylvania constitutes
an ideal location for this research in that it has both a large number of emergency medical
services providers more than 13,000 full-time, paid providers (Department of Labor,
2011) and displays a substantial call volume approximately 1.8 million calls for
service in 2008 (PA BEMS, 2009: 1). The choice of EMS agencies was purposive, with
the primary criteria being both high call volume and variation in organizational
arrangement (e.g., fire department based EMS, police department?based EMS, and
hospital-based EMS), while remaining similar in demographic and geographic

April 2013 Alexander C. Henderson & Sanjay K. Pandey 11

characteristics (West, 2001). Interviewees for this study were randomly chosen from a
population of on-duty paramedics over a two- to three-day interview period for each of
the three agencies. The interview process outlined below was pilot tested with
paramedics from EMS agencies not involved in the formal study. Paramedics selected for
participation were employed in a full-time capacity, and were primarily engaged in
emergency (9-1-1) transportation services.

Semi-Structured Interviews: Narratives of Street-Level EMS

Semi-structured interviews were conducted to collect narratives of street-level EMS
provision, with an emphasis on incidents that were particularly memorable, complex, or
challenging. Narrative inquiry has a number of strengths for the study of frontline work
(Bailey and Tilley, 2002; Connelly and Clandinin, 2006; Kelly, 1994; Maynard-Moody
and Musheno, 2003) in policy analysis and implementation (Roe, 1994). Stories allow
for investigation of complex interactions among a number of variables and locate these
interactions within a specific context, and can move beyond simple description to
“encompass the hows of people’s lives (the constructive work involved in producing
order in everyday life) as well as the traditional whats (the activities of everyday life)”
(emphasis in original, Fontana and Frey, 2005: 698).

The narratives included in this paper were selected for comprehensiveness, allowing
for the identification of the nature of the situation, the impressions and reactions of the
paramedics as they provided patient care, and the influence of supervisors who shaped
paramedic behavior. Narratives were analyzed using a grounded theory approach
(Charmaz, 2005; Glaser and Strauss, 1967), appropriate in that it permits exploration of
data in a manner that highlights “enacted processes, made real through actions performed
again and again” (emphasis in original, Charmaz, 2005: 508).

FINDINGS

Two narratives of street-level patient care are presented and discussed below, focusing
in particular on instances of disagreement or conflict with supervisors and the resulting
behavior of paramedics. Narratives presented here serve as important cases of response
to conflict in manager-worker interactions. The first incident illustrates deference to
supervisory directives, followed by a case outlining deviation.

Compliance with Directives: Paramedic Acquiescence Despite Disagreement

Paramedics routinely respond to emergencies for patients in cardiac arrest, enacting
precisely defined clinical protocols as they work collaboratively to bring patients back to

12 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1
Supervisor-Worker Interactions in Emergency Medical Services

life. Noting that this first incident was abnormal, the narrator highlights the potential
presence of a toxin and the associated risks that may be present for the patient and
responders alike. The resulting interactions between the narrator and the supervisor
illustrate tension between ideas of appropriate action, but ultimately result in deference to
supervisory directives.

We had a guy outside working doing yard work. He had a lot of pesticides; just
the regular stuff that you buy at Home Depot.[…] We pull up, […] there’s an older
gentleman standing in the driveway and a female […] doing CPR on a guy.[…] So I
called for the supervisor because my partner was pregnant. She’s due any day now.
I called for the supervisor to come give us a hand.

We worked him. I actually tried to intubate him.[…] Just got the laryngoscope in
his mouth, and went to put the tube in his mouth and blood just came out
everywhere. So, my supervisor, after the call was all over, the supervisor is
thinking that this could have been [caused by] a pesticide, because any toxin could
have started the pulmonary edema.[…] But, this was bright-red blood, so I wasn’t
thinking pulmonary edema.

But, the boss, he took it his way, and we started the whole HAZMAT thing.[…] So,
when it was all over with, me, my partner, the lady, my supervisor, we all had to go
[…] through showers, evaluations, and the whole nine yards. I got a couple of
specks of blood on me that was it for me.[…] A little bit of blood is not going to
bother me as long as I know that my hands are not all chopped up. But, yeah, that
was annoying. I think that was a little asinine myself. I kinda disagreed with it […]
but you have to go with the program. I wasn’t happy with it, I wasn’t happy at all.
“This is [ridiculous]. Really? I gotta get [decontaminated] for what? I got a couple
of specks of blood on me.” But, yeah, that really twisted me up a little bit.

I was a little perturbed. “Are you kidding me, man? Seriously? I’ve got to do all
this? For what?” We had to clean the ambulance, go clean ourselves, we had to [be
decontaminated], we had to be evaluated by the doctor, then had to come back, had
to clean all our [equipment] up. It was your typical cardiac arrest turned into a
possible pesticide poisoning.

“Really? Seriously, we gotta do this?” “Yeah.” I think his main thought process
was that my partner was pregnant, nine months pregnant, this other lady did
mouth-to-mouth me personally, I could have washed my hands with soap and
water and been on my way back in service. My partner didn’t get messy, it was the
lady who did CPR, if anybody. There [were] no blood splashes, there was no

April 2013 Alexander C. Henderson & Sanjay K. Pandey 13

offing of gases, or anything. Didn’t get […] lightheaded, no nausea. It was your
typical cardiac arrest. “Really? We gotta go do all of this?” [My supervisor] needed
to cover [himself]. I guess that’s just part of being a supervisor.

Upon arriving and assessing the scene, the supervisor and the narrating paramedic
suspected different causes for the patient’s condition, both with different resulting
treatment plans. Though the rules for treating a cardiac arrest patient are strict and
proscribed, those for identifying and declaring a hazardous materials incident are less
distinct, especially on a small scale as described in this incident. Noting the possible risk
to the responders and the bystander who had attempted to resuscitate the patient, the
supervisor made the discretionary decision to treat the scene as a hazardous materials
incident. In doing so, the supervisor drew on both the clinical protocols and formal
organizational authority as the foundation for his decision.

The results of the supervisor’s discretionary decision on the responding paramedics
were notable. A standard incident would require only a routine clean up and restocking
of the ambulance. This incident, and the supervisor’s decision to label it a hazardous
materials incident, required decontamination of personnel, bystanders who rendered care,
vehicles, and equipment, and a post-incident evaluation by an emergency department
physician.

While indicating his displeasure with the complex and time-consuming
decontamination process, the narrator also recognized the need to “go with the program.”
The supervisor’s decision to treat the situation as a hazardous materials incident
represented at the same time a stance that was markedly different from that of the
narrator, but one that was also distinctly aimed at protecting the health and safety of the
responders. The narrator also understood the need for the supervisor to “cover” himself,
displaying caution in a situation imbued with risk for both patient and providers. For
these reasons, the paramedic relating this story was willing to go through the extra steps
required for decontamination.

Deference to a supervisor in cases of conflict was not, however, the only response to
direct orders to street-level EMS providers, and examination of a case that stands in
contrast to the narrative of compliance presented previously will provide a more
balanced perspective.

Disregarding Directives: Paramedic Discretion and Patient Outcomes

An incident recounted by a paramedic illustrates a demonstrable conflict between a
treating paramedic and a frontline supervisor in terms of individually held concepts of
what constitutes appropriate care. The case below highlights the importance of
situationally contingent knowledge and action in EMS, and describes measured and
purposeful deviation from a supervisory directive to engage in specific patient care

14 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1
Supervisor-Worker Interactions in Emergency Medical Services

activities.

We got called to an accident up on [a four-lane roadway], and it’s a fairly
busy intersection. It was a low-impact accident, and I get there and there’s a
guy […] kind of leaning over between the two seats. And he’s complaining
of neck pain. So I walked up and I went to [stabilize his spine], and he tried
to move his head, and I felt some grating, and I’m just like, “That’s not too
good.” And during talking to him I asked him his name.[…] [He] was a
physician from [a local hospital].[…] And it turns out he had a fractured
[spinal vertebra]. So here’s this physician.[…] I’m assuming he knew what
was going on, because he told me, “I think I might have broken my neck,”
and when he tried to move a little bit, I felt the grating of it, and I’m like, “I
think you did too, don’t move.” And actually […] we wanted to fly him [via
helicopter] to [a regional trauma center] because it was a spinal injury. And
my boss at the time […] shot me down for it.[…]

We’re seven minutes from trauma center by ground. And I said [to my
supervisor], “Yeah, you’re right. You’re absolutely right, but we have to go
down bumpy […] streets, we have to cross trolley tracks and everything like
that.” I just didn’t feel comfortable driving even though, yes, [it was] seven
minutes away. And again, he wasn’t on scene to make that determination.
He didn’t know what I knew.[…] We would have been going down trolley
tracks the whole way.

And so we ended up flying him because I didn’t listen to what my boss
said. [The patient’s] outcome was actually pretty good. He was walking
around with a walker for a little bit, but then he made a full recovery. That
was one of the challenging calls, I think.

The responding paramedic presenting this case realized upon a more detailed
assessment of the patient’s condition that the injuries could potentially result in paralysis
or death. Typically, a severely injured patient would be transported by ground to a
regional trauma center, however the paramedic suspected that the patient had broken his
neck, thereby complicating the transportation decision. The clinical protocols addressing
the selection of the method of transporting a patient in this particular situation give wide
discretionary latitude to the treating paramedic. Though criteria are established to guide
this decision, the paramedic providing patient care is charged with the interpretation of
policy and final decision on method of transport. This ability to make the “final call” may
be further restricted within EMS agencies through the creation of organizational
procedures that give authority to paramedic supervisors. This was the case in the

April 2013 Alexander C. Henderson & Sanjay K. Pandey 15

narrator’s story; though he was not on the scene of the accident, the supervisor instructed
the paramedic to cancel the helicopter and transport the patient to the trauma center in the
traditional manner.

Interestingly, the supervisor’s decision does not take into account the experience and
judgment of the paramedic directly providing care. A less-experienced paramedic, or one
who was more inclined to follow the directives of the supervisor, could have simply
followed the order and risked a potentially life-altering trip down poorly surfaced roads.
The narrator of this incident, however, decided to exercise his professional judgment and
made a purposeful choice to call for a helicopter, a decision intended to reduce the
chances of further serious injury.

Both incidents recounted here illustrate the possibility of direct supervisory input into
the processes of policy implementation and patient care, and the possibility of disparate
ideas of what constitutes appropriate behavior. The responses of the narrators, though,
were on opposite ends of a spectrum; one incident resulted in compliance with an order,
the other in deviation. Highlighting key aspects of these incidents in tandem will
contribute to an improved understanding of these interactions.

DISCUSSION AND CONTRIBUTIONS

The narratives presented here reflect the complexity, uncertainty, and urgency found
in many street-level EMS incidents. The need to respond to situational contingencies
places stress on paramedics attempting to implement substantial yet imperfect rule sets, a
situation made increasingly complex by the intervention of direct supervisors. In both
incidents, paramedics were faced with a decision to act in a manner that was not fully
illustrated or specified by clinical rules and, in each case, the exercise of discretion was
necessary. Efforts by a supervisor to reduce discretion through direction were evident in
both cases, with both supervisors indicating that specific behaviors were appropriate to
the situation. In both instances, the narrator’s assessment of what would be the most
appropriate action conflicted with the supervisor’s conceptualization of the appropriate
action, and some amount of purposeful internal deliberation within the narrator was
initiated.

In the first incident, characterized by eventual agreement with the supervisor, key
considerations were focused on the possible viability and veracity of the supervisor’s
conceptualization of the situation, possible harm to colleagues and bystanders, and an
absence of detrimental effect to the patient. The supervisor’s proximity to the incident
and knowledge of the possible effects of toxins were plausible, and thus the narrator,
though somewhat unhappy with the added complexity of applying the hazmat label to
the situation, acquiesced. The decision to accept the supervisor’s ruling and proceed with
decontamination and physician exam was supported by the consideration of possible

16 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1
Supervisor-Worker Interactions in Emergency Medical Services

harmful effects to both the bystander who had rendered care and the narrator’s partner.
In the second incident, characterized by deviation, patient need and potential patient

outcomes took center stage. The paramedic established his own conceptualization of
appropriate patient treatment behavior, which was then countermanded by his supervisor.
The supervisor’s distance from the incident, lack of specific situational knowledge about
patient condition and clinical needs, and failure to understand possible patient outcomes
that may have resulted from the directive were central. Deviation, then, was necessary to
avoid exacerbating a potentially devastating condition and ensure the best possible
outcome for the patient.

In both incidents a number of key factors were evident in the decision to follow or
ignore the supervisor ’s directive. First, cognizance of conflict or the potential
inappropriateness of a supervisor’s directive was notable, thus signaling that the
paramedic’s knowledge of clinical and operational rules, and situational or local
knowledge are important preconditions to the decision to follow or deviate from orders.
Once conflict was evident, the supervisor’s clinical or operational expertise or credibility,
as well as the supervisor’s local or situational knowledge, were important in the
paramedic’s judgment of the appropriateness of the directed action. Being present at an
incident and understanding the requirements of patient and scene management were key
to establishing a basis for following or deviating from a directive. Finally, considerations
of the potential outcomes for EMS providers, bystanders, and patients were notably
important. The particular possible outcomes for each category of individual on scene
were central to a decision to comply with or ignore orders.

In these instances factors such as expertise and situational knowledge for both the
street-level bureaucrat and the frontline supervisor were critical in understanding both the
identification of conflict and the decision to comply with, or deviate from, a supervisory
directive. Given that many of these decisions are shaped through experience with
particular types of situation and experiential learning, this lends support for theories of
street-level bureaucracy that place emphasis on occupational culture (Isett, Morrissey,
and Topping, 2006; Riccucci, 2005; Sandfort, 2000). Likewise, an understanding of the
possible outcomes both for crew members and patients was crucial in understanding the
decision to comply or deviate.

A number of practical considerations evident here may be of interest for future
empirical research. First, in both cases communication between frontline providers and
supervisors was crucial in the process of creating, or failing to create, understanding.
Creating a firmer foundation for individual decision making through clearer
communication could allow for reduced chance of error that may impact the safety of
both crew members and patients. Second, in both cases situational knowledge was
important for both frontline workers and supervisors, with increased expertise and
experience potentially leading to increased trust in difficult and complex situations.
Finally, the situationally specific knowledge that results from incidents like these may be

April 2013 Alexander C. Henderson & Sanjay K. Pandey 177

valuable to other paramedics after the fact. The expertise that served to potentially
improve patient outcomes or ensure crew member safety in these incidents may be
transferrable in post-incident debriefings or case study discussions among EMS
providers.

CONCLUSION, LIMITATIONS, AND FUTURE RESEARCH

This exploratory study of leader-worker interactions in EMS represents an important
area of focus for future inquiry. EMS is fundamentally different from welfare eligibility
work, community policing, and other line-level functions, thus bringing to the fore
considerations for leadership on the part of managers and supervisors in the profession.
Though definitive conclusions about these interactions cannot emerge from the
discussion of these narratives, the findings presented here do indicate that this is an
emerging area of inquiry. Formal leaders in EMS should consider both the expertise and
intentions of EMS providers as they engage in service provision, acknowledging that the
situationally contingent use of discretion may be critically important to patients and can
be construed as leadership in and of itself (Vinzant and Crothers, 1998). The results of
managing for compliance versus managing for outcomes may be tremendously different,
and the implications for individual patients may be great.

A number of limitations of this research are notable. First, this article reports only two
service interactions illustrating conflict in manager-worker relations, a number that is not
representative of a full body of these interactions or incidents in street-level EMS.
Related to this, this research only considers the interactions of street-level workers and
their direct supervisors during emergency incidents, and does not consider interactions
outside of emergency incidents. Though necessary for the purpose of this study, selection
of participating agencies and paramedics was not random, thus allowing for possible
biases. Finally, although well suited for this study, the stories presented here are not
objective fact, but rather individually constructed interpretations of events (Maynard-
Moody and Musheno, 2003: 26). Indeed, the stories presented by participating subjects
may only represent cases that the participants deem to be acceptable for presentation
(Maynard-Moody and Musheno, 2003: 32). As this study is exploratory in nature, these
limitations are acceptable.

Future research should extend, refine, or challenge the stories in this study, focusing
on narratives that support or run counter to those found here. Other means of collecting
data, including direct observation of incidents or participant observation with follow-up
interviews, should be considered to provide a more robust idea of the causal relationships
at work. Likewise, examination of interactions with other individuals with legal authority
to provide direction should be pursued, with a specific focus on the physicians who staff
emergency departments and provide clinical guidance to paramedics operating in the

18 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1
Supervisor-Worker Interactions in Emergency Medical Services

field. The examination of public, private, and nonprofit services located in urban,
suburban, and rural contexts is also important, as is the study of EMS personnel with
varying levels of training and experience.

This exploratory work can serve as a call for more focused examination of this
important area of public service. Continued refinement and reevaluation of our
understanding of the interactions between street-level EMS workers and leaders in EMS
is crucial given the critical nature of this core public service.

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Alexander C. Henderson is an assistant professor in the Department of Health Care and
Public Administration at Long Island University. He holds a PhD in public
administration from Rutgers University-Newark, and previously served as a chief
administrative officer, operational officer, and board member for several emergency
services organizations in suburban Philadelphia. Email: alexander.henderson@liu.edu

Sanjay K. Pandey is a professor in the School of Public Affairs and Administration at

22 Leadership in Street-Level Bureaucracy: An Exploratory Study of Vol. 18, No. 1
Supervisor-Worker Interactions in Emergency Medical Services

Rutgers, The State University of New Jersey, Newark. His research interests are in public
management and health policy. Email: skpandey@newark.rutgers.edu

Received:

April 2013 Alexander C. Henderson & Sanjay K. Pandey 3 23

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https://www.researchgate.net/publication/283987859

J. Basic. Appl. Sci. Res., 2(9)8833-8842, 2012

© 2012, TextRoad Publication

ISSN 2090-4304
Journal of Basic and Applied

Scientific Research
www.textroad.com

*Corresponding Author: Agusthina Risambessy, Department of Buisness Administrative, Faculty of Administrative
Science, University of Brawijaya, Malang of Indonesia. Email: austhin_r@yahoo.com

The Influence of Transformational Leadership Style, Motivation, Burnout

towards Job Satisfaction and Employee Performance

Agusthina Risambessy1*, Bambang Swasto2, Armanu Thoyib3, Endang Siti Astuti2

1Department of Management, Faculty of Economic, University of Pattimura, Indonesia
2Department of Business Administration, Faculty of Administrative Science,

University of Brawijaya, Malang, East Java of Indonesia
3Faculty of Economic and Business, University of Brawijaya, Malang, East Java of Indonesia

ABSTRACT

Changes in organizational structure, vision and changes leadership is inevitable in any institution. Leadership
style is a special characteristic that distinguishes a leader from one another and this is a powerful force to move
the employee or employees in completing work toward the achievement of maximum results, especially in
improving public health services in environment compete. This research aimed to describe and analyze the
influence of transformational leadership styles, motivation, burnout, and job satisfaction and employee
performance. The unit of analysis is nursing paramedic at a hospital in Malang Raya. Data collection
techniques: conduct interviews using questionnaires and observation techniques as well as using SEM analysis
tool with 105 respondents in a hospital. The research proves that: Transformational leadership style with ideal,
indicator: the influence of leader behavior, intellectual stimulation, a consideration of the individual has a
significant and positive influence towards motivation. Transformational leadership style had a significant and
negative influence on burnout. And directly influence is stronger than the influence of indirect. This proves that
the intervening variables mediated transformational leadership style with burnout cannot be ignored.
Transformational leadership style has significant influence and positive toward job satisfaction.
Transformational leadership style has significant and positive influence toward employee performance. This
indicates that transformational leadership has a direct role to increase motivation, pressing the occurrence of
burnout among nursing paramedic, improving job satisfaction, and performance of a paramedic nursing hospital.
Motivation with an indicator: the need for existence; the need for relation and the need for growth have leverage
significant negative and burnout against. Motivation has significant and positive influence toward job
satisfaction. Motivation has significant and positive toward employee performance. This gives the meaning that
motivation has a very important role to improve the performance of employees. Prevent the occurrence of
burnout among the paramedics nursing as well as the improved employee of Malang Hospitals. Burnout with
indicators: mental, physical and emotional exhaustions have significant influence and negative towards job
satisfaction. Burnout has a significant negative influence on performance and employees. This shows that
burnout has influence directly to lower job satisfaction and performance of employees within the hospital
nursing paramedic of Malang Raya. The satisfaction of working with indicators: the work itself, a chance to be
promoted, supervise, rewards and support a co-worker has a positive and significant effect on the performance
of employees. This gives the meaning that job satisfaction was instrumental to increase employee performance.
Keywords: Transformational Leadership Style, Motivation, Burnout, Job Satisfaction and Employee
Performance

INTRODUCTION

The company as a forum and process of various activities that are planned and organized in the
framework of the achievements of objectives is thus an important element of the Organization management
wheel. Human resources are the most important asset in a company or organization. Employees can become
potential if managed properly and right, but will be burdens if improper manage. Quality of human resources
will be a power for management and support the performance of a company or organization that achieve good
purpose. General Hospital is an institution for social service activities where public health is provide public
health services, and it open 24 hours, porvide services to patient whether it impatient, emergancy treated or
outpatient, both has severe disease or a light disease. Lack of paramedics and rising of arrival patient is the
problem that faced by the hospital, on the other side, the paramedics has to provide maximum service that
becomes focus in this research.

A style of transformational leadership can provide a positive influence toward performance and attitude
of followers [1]. Granting of work motivation is a raises morale or motivation of working individuals are
influenced by the needs system. Therefore, any organization is required to plan, organize, and provision a

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facility that is needed to meet the needs of employees. The form of worries facing a worker, for example, the
threat of dismissal, the mutation of position is incompatible with desire, lack of welfare, moreover , it is often
flow to the path of emotional sadness. The lack of that feelings will be show psychology discipline as emotional
exhaustion. According to Babakus et al., [2], based on the emotional exhaution is Burnout, but Burnout is not
the only one form of emotional exhaution.

Research problems is: Whether leadership style has significant influence toward motivation, Burnout, job
satisfaction and employee performance? Whether motivation has significant influence toward Burnout, job
satisfaction and employe performance? Whether Burnout has significant influence toward job satisfaction and
employee performance? Whether job satisfaction significant influence toward employee performance?

Research Purpose: Analysis and explain the influence of transformational leadership style toward
motivation, Burnout, job satisfaction, employee performance. Analysis and explain the influence of motivation
toward Burnout, job satisfaction, employee performance. Analysis and explain the influence of Burnout toward
job satisfaction of employee and employee performance. Analysis and explain the influence of job satisfaction
toward employee performance.

MATERIALS AND METHODS

Empirical Research

Alan J. Dubinsky, et al., [3] research result found that: 1). Role conflict has positive relationship with
role of ambiguity, 2). Role conflict has no significant influence toward performances. 3). Role of ambiguity
decrease performance and organization comitment, 4). Role of ambiguity has no relationship with job
satisfaction, 5). Performance has positive relationship with job satisfaction, 6). Job satisfaction has positive
relationship with organization comitment.

Daniel C. M. et. al, [4] result showed that: 1). Salesperson that overload level has high role, also has high
level of job presure, 2). Salesperson that has highest feedback from its manager has low role of ambiguity, and
them which obtaint high otonomy of conflict has low role , 3). Salesperson that has high atitude type A realized
role conflict and also has high overload role.

Low and Cravens [5] proved that higher intrinsic motivation, lower role conflict in salesperso,. higher
intrinsic motivation level, lower ambiguity role of salesperson. Higher intrinsic motivation level, lower Burnout
in salesperson ground, Alf Crossman [6] “ job satisfaction and official performance on staff of Lebanon banks”
research result show that all of job satisfaction has significant relationship with official performance. Elencov
[7], research result found there had positive significant among tranformational leadership bahavior with
organization performance than transactional leadership behavior.

Hypothesis
H1: Transformationnel leadership style has signifiant influence to motivation.
H2 : Transformationnel leadership style has signifiant influence to Burnout
H3 : Transformationnel leadership style has signifiant influence to job satisfaction.
H4 : Transformationnel leadership style has signifiant influence to employée performance.
H5: Motivation has significant influence to Burnout.
H6: Motivation has significant influence to job satisfaction.
H7: Motivation has signifiant influence to employée performance.
H8: Burnout has significant influence and negative to job satisfaction.
H9: Burnout has signifiant and négative influence to employée performance.
H10: Job satisfaction has significant influence to employee performance.

Research Methodology
This explanatory research is a kind of resarch that try to explain relationship among variables through
hypothesis test. Unit of analysis in this research is paramedics of Malang hospitals. Research population is
Malang hospitals that consist of Malang Regency, Malang City and Batu Malang City. It takes 6 hospitals at
Malang Raya area.Sampel of this research is nurse paramedics that use as responden. Sample size using Slovin
formula with 5% of galad precision. Base on calculation with Slovin formula get 105 people as sample size.

Data Collection Techniques

Data collection techniques use:
a) Questionaire, it become main instrument in this research that address to respondent.
b) Interview, is a technic to collect data with direct interview to respondent.
c) Documentation is a technic to learn exist company document that related with reasearch problem.

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J. Basic. Appl. Sci. Res., 2(9)8833-8842, 2012

Reliability of research instrument and validity test show that all research instrument is valid and
reliable. Where, alpha coefficient value bigger than 0.6. Method of data analysis devided into two group, that
is analysis of statistic descriptive and analysis of statistic inferential. Analysis of statistic descriptive is use to
know frequency distribution answer of respondent from questionaire result. Descriptive measurement is
provision point, better in respondent ammount with average rate answer of respondent or it precentage.

Analysis of Statistic Inferential

Analysis of statistic inferential used to test influence of every variables. Using Structure Equation Mode
(SEM) as a technic of statistic analysis. Structural equation, is a formula to show causality relationship among
every construct.
Endogen Variable = Exogen Variable + Endogen Variable + Error
Y2 = X1 + X2 + X3 + Y11 + ℰ
Y1 = X1 + X2 + X3 + ℰ
X3 = X1 + X2 + ℰ
X2 = X2 + ℰ

Operational Definition and Measurement Variable

Operational definition is meant to explain every variables as construct indicator or laten variable in this
research. In order that there is no misunderstanding or different opinion.

Transformational leadership style is an approach way that used by leader to influence staff to reach
organization purpose, Subbak [8]. Leadership that will be research is installation leader, room leader, and unit
leader. Operational variable that used to measure is transformational leadership, absorb from Wood et al, [9] as
follows:

1. Ideal influencio becarme as the example and a proud leader.
2. Leader behaviour is as independent leader with motivated people that stays arround

by giving the meaning and challenge to employee work which covers to unite the vision
and mission.

3. Intelectual stimulation that is leader stimulate staff being more: giving reward to
employee, and develop new idea.

4. Individual consideration that is leader giving atency to individual need by focused on
abilty, where leader become trainer, and direct communication.

Motivation is the potential power that inside a person that can be developed by some outside

force/essentially revolves around the monetary or non-monetary rewards that can influence the results of the
performance of both positive and negative, and it really depends on the situation and condition of the person. In
this research, indicator and variable adopted from Clayton Alderfer ERG teory, that is:

1. Need of existence that is a need which related with directly life which covers the needs about
fulfilled monetary.

2. Relation need or relatedness, is to emphasize the important of social relationship and
relationship among individual that cover relationship of the leader with subordinate, subordinate with the
leader, relationship of the leader with the leader, and work partner relationship.

3. Need of growth, is a need that related with intrinsic desire, individual toward personal development as a
chance to follow education and training.
Burnout is an exhaustion that unite according to physic, mental and emotional. This measurement of

Burnout variable is physical exhaustion, mental exhaustion and emotional exhaustion.
1. Physical exhaustion is the helplessness to face work situation like feel exhaust and isolated.
2. Mental exhaustion is the helplessness to work situation as consequence of job tension that

influence someone psychology like: Feel depression and worried.
3. Emotional exhaustion is the helplessness to control emotion when facing work situation that influence

someone emotion like feel priceless and rejected [9].
Job satisfaction that is an attitude of someone toward things that related with occupation [10].

Measurement of job satisfaction variable in this research adopted from Lock in Robbins [11] that is job
satisfaction aspects that consist of:

1. The work itself, to which it gives to the individuals: every interesting work, the value of the
work itself is a source of satisfaction

2. The opportunity to be promoted is opportunities to occupy the higher level of the hierarchy are
available within an organization, namely, the opportunity to excel and aspects of fairness.

3. Supervision is the ability of leadership to provide technical assistance and support to implementation of
work behavior employees provide support, the degree of freedom.

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4. Rewards that are a number of financial rewards received by employee who was seen more as justice to the
workers in accordance with salary expectations, to a fair salary, awards and benefits.

5. Support partners, other employees are working in a job that shows the friendly attitude and encourage an
increase in achievement through each other, provide support.

Performance is the result of work achieved by one employee/subordinate in carrying out the work in
accordance with the criteria set for the work. [12]. The performance of the work even of quantity as well as
quality based on standard work which has been determined. [13]. The performance of employees in this research
is paramedic nursing. Intended with paramedics nursing are employee that deals / in direct contact provide good
care services to hospital patients, nurse emergency and outpatient. [13]. Six primary criteria that can be used to
measure employee performance. Those criteria will be used in this research for measuring employee
performance as follows:

1. Quality that is the result of the implementation of the activities of accomplished
service by giving priority to quality and accuracy.

2. Quality that is the result of accomplished services by responsibility that provided
according to working time or exceed working time.

3. Timeliness that is the lenght of an activity are resolved fast and influenceive.
4. Cost efectiveness that is the influenceivelly and efficiently magnitude of organization

resources.
5. Need for supervision that is the ability of the employee to perform job functions that

require supervision of a supervisor to prevent unintended actions.
6. Interpersonal impact That is the ability of an employee to maintain self-esteem, good

name in building working relationships of work environment and society.

RESULTS AND DISCUSSION

The results of hypothesis test can be seen in the table as follows:

Table 1 Loading Factor () Test Model Relationship Of Variable Leadership Style, Motivation, Burnout Toward
Job Satisfaction and The Final Stage Of Employee Performance.

H

Independent Variable Dependent Variable Loading
Factor

t
count

p value
Decisions

H1 TLS Motivation 0.670 6.537 0.000 Acceptable
H2 TLS Burnout -0.323 -2.685 0.007 Acceptable
H3 TLS Job Satisfaction 0.204 2.089 0.037 Acceptable
H4 TLS Employee Performance 0.184 3.100 0.002 Acceptable
H5 Motivation Burnout -0.277 -2.222 0.026 Acceptable
H6 Motivation Job Satisfaction 0.548 5.324 0.000 Acceptable
H7 Motivation Employee Performance 0.582 6.200 0.000 Acceptable
H8 Burnout Job Satisfaction -0.084 -3.168 0.003 Acceptable
H9 Burnout Employee Performance -0.087 -2.620 0.009 Acceptable
H10 Job Satisfaction Employee Performance 0.255 4.130 0.000 Acceptable

Source: Processed Data Primer on (2010)

Based on the results of the calculations can be known that all significant influence is visible from t
count is below 1.96 and p value ≥ 0.05. Can be explaining as follows:

1. Transformational leadership Style significantly influence toward motivation of the rate of t count =
6.537 and rate of p value = 0.000, and loading factor as big as 0.670. These coefficients showed that
transformational leadership style will result in high motivation.

2. Transformational leadership style significantly influence toward Burnout, seen from the rate of t count
= (-2.685) and rate of p value = 0.007, and loading factor as big as (-0.323). These coefficients showed
that by applying the transformational leadership style will improve the paramedic nursing.

3. Motivation significantly influence toward Burnout seen from the rate of t count = (-2.222) and rate of p
value = 0.026, and loading factor as big as -0.277. These coefficients showed that by having
motivation will prevent Burnout.

4. Motivation significantly influence toward job satisfaction seen from the rate of t count = 0.5324 and
rate of p value = 0.000, and loading factor as big as 0.548. These coefficients showed that by having
motivation will produce job satisfaction.

5. Motivation significantly influence toward employee performance, seen from the rate of t count = 6.200,
and the rate of p value = 0.000 and loading factor as big as 0.582. These coefficients showed that by
having motivation will produce high performance in paramedics nursing.

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6. Burnout significantly influence and negative toward job satisfaction seen from the rate of t count = (-
3.168), and the rate of p value = 0.003 and loading factor as big as -0.084. This showed that job
satisfaction felt by the paramedic nursing depends greatly on the conditions of work and the workplace
environment.

7. Burnout significantly influence and negative toward employee performance, seen from the rate of t
count = (-2.620) and the rate of p value = 0.009, and loading factor as big as 0.087. These coefficient
shows that weigh pressure of hard work and some work can influence level performance that will be
produce by paramedics nursing.

8. Job satisfaction significantly influence toward employee performance, seen from the rate of t count =
4.130 and the rate of p value = 0.000, and loading factor as big as 0.255. These coefficients showed
that by having complacence work will influence employee performance.

Thus, the hypothesis results test shows that:
H1: Transformational leadership significantly influence toward motivation has significant level as big as p

= 0.000 (acceptable hypothesis).
H2: Transformational leadership style significantly influence to Burnout, significant level of p = 0.007

(acceptable hypothesis).
H3: Transformational leadership significantly influence toward job satisfaction. Significant level as big as p

= 0.037 (acceptable hypothesis)
H4: Transformational leadership style significantly influence toward employee performance. Significant

level as big as p = 0.002 (acceptable hypothesis).
H5: Motivation significantly influence toward Burnout. Significant level as big as p = 0.026 (acceptable

hypothesis).
H6: Motivation significantly influence toward job satisfaction, significant level as big as p = 0.000

(acceptable hypothesis).
H7: Motivation significantly influence toward employee performance, significant level as big as p = 0.000

(acceptable hypothesis).
H8: Burnout significantly influence and negative toward job satisfaction, significant level as big as p =

0.003 (acceptable hypothesis).
H9: Burnout significantly influence and negative toward employee performance, significant level as big as

p = 0.009 (acceptable hypothesis).
H10: Job satisfaction significantly influence toward employee performance, significant level as big as p =

0.000 (acceptable hypothesis).

Overall result test can be described in the following model as in Figure 1

Figure 1 Overall result test

Source: Processed Data on 2011

This discussion will attempt to answer the formulated problem, by using the method of SEM (structural
equation modelling) in aid of AMOS 16.0 program and coefficients and the standards of significance will be
discussed whether a hypothesis that is supported and formulated by accepted fact or rejected based with
necessary explanations.

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Risambessy et al., 2012

The Influence of Transformational Leadership Style of Motivation
Base on the results of through testing of structural equation modeling showed tranformational leadership

style significantnly positive and significantly toward motivation with P = 0.000 (<0.05), and the rate of standardized regression weights/loading factor as big as = 0.670 and the rate of t count (critical ratio) = 6.537. This findings support the research results from Mehta et al., (2003). However, researches results of Mehta et al., (2003) with significant level are 0.051, if seen from reliable degrees 0.95%, then the result has strength influence from this research. Based on result test, shows that transformational leadership style significantly influence and positive toward motivation. This give sense that a leader who implement transformational leadership could increase highes motivation to paramedics environment. This findings make strong Mehta research et al., (2003), that study about relationship among different leadership style that can be used as another strategy to increase other partner motivation, and to know the different of leadership style among several countries, and to know other partner motivation toward performance. The truth of leadership style is the main element of one leader to determine attitude into formulated doctrine, institution program, and to direct the activity in institution relationship with its environments [14]. When organization is fluctuated and uncertainty, role of the leader is needed. The leader who has mision surely will be able to manage organization and every resources which support leader.

In this leadership style, the leader comunicate its desire to concrete organization purpose by vision,
mision and ask other people to be allied to reach purpose with using resources and energy in efficiently [14].

The Influence of Transformational Leadership Style Toward Burnout

Result test by structural equation modeling showed transformational leadership style influence negative
and significant toward motivation with P = 0.007 (<0.05), and the rate of standardized regression weights/loading factor as big as = -0.323 and the rate of t count (critical ratio) = -2.685. Based on that result test, showed that transformational leadership style significantly influence and positive toward Burnout, this give meaning that a leader who implemented transformational leadership style can prevent burnout in paramedics environment.

According to complexity resource in hospital needed leadership to activate source by four factor [15]
that is 1). Leadership hospital, 2). Coordination that developed by every vice directur and instalation leader 3).
Comitment and professionalism of paramedics and non medic sources 4). Understanding of sevices user as
services type that available at hospital.

The Influence of Transformational Leadership Style Toward Job Satisfaction
The result test by structural equation modeling showed transformational leadership style influence
positive and significant toward job satisfaction with P = 0.037 (<0.05), and the rate of standardized regression weights/loading factor as big as = -0.204 and the rate of t count (critical ratio) = 2.089. This research showed that significantly influence among transformational leadership with job satisfaction signed by path coefficient. That things seen from the rate of standardized regression weight as big as = 0.138.

This findings support research result of Mitzi N. Stumpf [16], Peter Lok and John Crawford [17],
Griffith James [18] says that Headmaster who implement transformational leadership style produce strong
relationship, positive and significant toward job satisfaction, and produce negative relationship that significant
toward employee turnover level, and toward student value achievements (output produce by student).

The Influence of Transformational Leadership Style Toward Employee Performance

To answer research problem (H4) as partial can be notice from SEM analysis result showed that
transformational leadership influence toward motivation. This can be proved with tha rate of t count (critical
ratio) = 3.869 bigger than the rate of t tabel 1.96, the rate of p = 0.000 more insignificant than  = 0.05. This
research also showed positive significant founded among transformational leadership style with employee
performance, that indicated with path positive coefficient. That can be seen from value ofstandardized
regression weight as big as = 0.185.

This findings make strong research of Emmanuel Ogbonna and Llyoyd C. Harris [19], Darwis A.
Yousef [20], Griffith James [21], Elencov [22]. Based on result test, indicate that tranformational leadership
style significantly influence and positive toward employee performance. This mean that a leader who implement
transformational leadership style can increase employee performance.

Every capability inside of leadership must inherent tight to every loaded space of a leader, and leader
responsibility because without more capabilities of human resources management, impossible the leader has
goog succeed to do leader resposibility. Transformational leadership style has big affet toward organization that
leader lead.

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Motivation Influence toward Burnout
To answer research problem (H5) as partial can be seen from SEM analysis result. Showed that the rate

of t count (critical ratio) = 3.934 bigger than t tabel = 1.96 or the rate of p = 0.000 more insignificant than  =
0.05. This research also showed that there is positive influence among motivation with Burnout, that signs with
coefficient of positive path. This can be seen from the rate of standardized regression weight = 0.414.

Result test signs that motivation give direct role toward Burnout. There are three main characteristics of
motivation that belongs by paramedic person, that is: 1) Effort, that is showed someone strength of job attitude
or total effort that shown by someone in their works, 2) strong willingness, that showed strong willingness
which demonstrated by someone in implemented his effort to job tasks, and 3) Direction or purpose, that related
with direction by strong effort and willingness of someone, that basically is benefit things. This research
support previous research of Low and Cravens [23]. Thus can be conclude that H5 state that motivation
significantly influence toward Burnout.

Motivation Influence toward Job Satisfaction

To answer the problem of (H6) as partial, can be notice from SEM analysis result, showed that
motivation influence toward job satisfaction. This thing proved by the rate of t count (critical ratio) = 2.620
bigger than the rate of t tabel 1.96 or the rate of p = 0.009 more insignificant than  = 0.05. This research also
showed positive relationship among motivation with job satisfaction which signs with positive path coefficient.
It can be seen from the rate of standardized regression weight as big as = 0.305.

Base on result test signs that motivation directly significant influence and positive toward job
satisfaction. According to Robbins [11], Gibson et al. [10], and Porter & Lawler says that motivation
significantly influence toward job satisfaction. Igalens & Roussel [24] also says that flexible pay that give to
employee not motivate and not increase job satisfaction, and benefit that give to permanent and not permanent
employee do not make employee motivated and do not increase job satisfaction. Thus H6 hypothesis state that,
motivation significantly influences toward job satisfaction, it can prove and support by empirical and fact.

Motivation Influence Toward Employee Performance

To answer research problem of (H7) as partial, can be seen from SEM analysis showed that motivation
significantly influence toward employee performance. This things can be proved by the rate of t count (critical
ratio) = 6.247 bigger than the rate of t tabel 1.96 or the rate of p = 0.000 more insignificant than  = 0.05. This
research also showed positive relationship among motivation with employee performance that signs with
positive path coefficient. It can be seen from the rate of standardized regression weight as big as = 0.294.

Based on the results of tests indicating that motivation influential significant and positive directly against
employee performance. This provides meaning that with giving motivate to the employee will increase
employees’ performance. Thus this finding supported previous research and supported by several theories
stating that motivation effect on employee performance [25][26].

Burnout Influence toward Job Satisfaction

The result of testing through structural equation unified showing significant and positive motivational
influence on the performance by employees P = 0.000 (<0.05) and the rate of standardized regression weights/loading factor as big as = -0.582 and the rate of t count (critical ratio) = 6.200. Based on that testing, signifying that burnout that effect toward employees satisfaction work.

The result of this research is to support research [23][27]. Researchers formerly found that fatigue
emotional is Burnout root formation that negative influential significant with objects research teachers and the
lecturer, institution sales with a pressure indicator work, and burden family. This organizations is quite different
from other public service organization that in the public service organization, such as private or government
hospitals, employee who ready to work already has professionalism soul, Alfonso and Korten into Tangkilisan
[14] says that profesionalism that is fitness among bureaucratic competence with task requirement. Fulfilling
fitness among employee competence with task requirement become rule to construct professionalism employee.
This mean, skill and competence of employee reflected direction and purpose that want to reach by an
organization. professionalism soul formed when follow education and training on education place.

Burnout Influence Toward Employee Performance

Result test of structural equation modeling showed Burnout berpengaruh signifikan significant influence
and negative toward nursing paramedics performance with P = 0.009 (>0.05) and the rate of standardized
regression weights/loading factor as big as = -0.087 and the rate of t count (critical ratio) = -2.620. that things
can be seen from the rate of standardized regression weight as big as 0.117, Burnout significant influence and
negative toward employee performance which is proved and acceptable in hypothesis 9. This findings support
result research of Alan Dubinsky et al.[3], Low and Cravens [23], Zagladi [27].

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Risambessy et al., 2012

Maslach [28] state that low personal accomplishment is a feeling of guilt, because it has been treating
client negatively [29]. The guilt it appears because they are always realizes that he had undergone chance to the
poor quality toward others. Burnout arises from the most emotional sources in, example is feeling frustrated,
despond, sad, helpless, depressed, apathy to work, sceptical of the environment, feel bound by duties in work, so
that someone feels doesn’t give psychologically services. Besides that looked is individual related easily
offended, easy angry without reasons and easy disappointed [29].

A wide range of feelings do not believe because of experiencing emotional exhaustion, is certainly
decrease work productivity. Company which profit oriented and nonprofit institutions, such as schools and
university, usually facing Burnout problems which came upon employees.

The Influence of Job Satisfaction Toward Employee Performance

Based on these test results, indicating that job satisfaction is represented by an indicator of the work
itself, a chance to be promoted, supervise, properly rewards and support colleagues can give direct influence
toward employee performance. It means that the higher satisfaction employees of work will be more producing
high performance by employees.

Thus this finding supported previous study and supported by several theories stating that performance in
form of quantity work, and quality work influence on work satisfaction. Robbins [11] state that influence from
job satisfaction toward employee performance is: 1) productivity; 2) absent; and 3) the level of output. Besides
that, job satisfaction gives influence toward employee performance, according to Handoko [30] is: 1) work
achievement; 2) rolling employee and attendance; 3) the age and level of work; and 4) large organization. Alf
Crossman (2000) research showed that job satisfaction in overall has significant relationship with employee
[31][32][33].Tthe results show that job satisfaction significantly positive influence on performance of
employees formed by indicator 1) attitude towards work, 2) partners, 3) supervisor, 4) support and policy
organizations, 5) salary, 6) promotion and progress, and7) customer.

CONCLUSION

Several conclusions were as follows:

1) Transformational leadership style with its indicator which used are: the influence of ideal, intellectual
stimulation, leader behavior, consideration of individual has significant influence and positively to
motivation. With significant stage (0.000). Transformational leadership style has direct role to increase
motivation that will produce by employees to organization.

2) Transformational leadership style has significant influence and negative towards Burnout. With
significantly stage of (0.007). This thing showed that transformational leadership style has great capability to
prevent Burnout. Direct influence more strong than indirect influence. This proved that variable intervening
that mediates variable transformational leadership style with burnout cannot neglect.

3) Transformational leadership style has significantly influence the job satisfaction. This indicates that
transformational leadership style has a direct role to generate job satisfaction for the nurses and midwives in
the hospital of Malang Raya. Indirectly influence is stronger than direct influence. Thus proving that variable
intervening mediated variable transformational leadership style with job satisfaction to note in measurement,
because it has a strong contribution.

4) Transformational leadership style has significant influence and positive toward employee performance.
This gives the meaning that transformational leadership style has a direct role to improve performance to be
generated at organization.

5) Motivation with indicator: the need for the existence/ of the existence has significant influence and
negative toward Burnout. This gives the meaning that motivation has a very important role directly to
prevent the occurrence of Burnout amongst paramedics nursing of Malang Raya hospitals.

6) Motivation has significant influence and positive toward job satisfaction. This gives the meaning that
motivation has a very important role to increase the work of employees through the fulfillment needs that
organization gives to employees.

7) Motivation has significant influence and positive toward employee performance. This thing gives the
meaning that motivation has a very important role to increase employee performance.

8) Burnout using indicators: mental, physical and emotional exhaustions have significant influence and
negative towards job satisfaction. This shows that Burnout has important influence to paramedics nursing to
decrease job satisfaction.

9) Burnout has significant influence and negative toward employee performance. This shows that the
indicators of emotional exhaustion as a shaper of Burnout have an influence directly and meant for
paramedic nursing in decreasing employee performance.

10) Job satisfaction using these aspects of job satisfaction as an indicator: the work itself, a chance
to be promoted, supervise, rewards and support a co-worker has a positive and significant influence on

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J. Basic. Appl. Sci. Res., 2(9)8833-8842, 2012

performance of employees. This give meaning that job satisfaction give meaning to increase performance by
giving assessment that appropriate with job and rewards appreciation achievement.

SUGGESTION

Based on the results of this research and some suggestions may be given to:

Hospital
1. Job satisfaction is one of the forming variables of employees attitude work that possibility of the creation

of bigger spoke positively about the Organization, performing beyond normal estimates, as well as
obedient to the call of duty. Therefore, it is advisable for the Manager to be able to pay attention to hospital
policies and procedures relating to the granting of rewards, whether it be rewarded oriented to performance
or oriented to giving right. Policies and procedures if it is run with a sense of Justice will provide a level of
satisfaction.

2. Research results prove paramedics nursing never experienced burnout one factor supporting is have souls
professionalism thus suggested to hospital management continue to fertilize soul professionalism to
employees and give attention to employees, Even give the opportunity to employees revealed what was
facing task that given to employees as a friend and can make friend discussion.

4. In order for the summit leadership and the manager can give you wide opportunity to next researcher to get
actual data of access information, so that scientific activities like this will not stop at a certain point.

Regional Government

1. Regional Government of East Java Province or District of Regional Government of Malang have
removed the system use labor honorary paramedics nursing, therefore need to pay attention to the
appointment of a civil servant’s candidate almost 29-30 r paramedics MPP/ year and patients number
even nurse emergency ambulatory, inpatient that still increase.

2. In order to implement the task of health care service that professional to embody the hospital services
are global standard, Regional government as a steward public service in public health should be more
continuous optimize leadership role work unit healthcare proactive to support excellent service, with
training exercise that focus on the aspect of management and executes program benchmarking as a
means to evaluate the development of an organization.

3. To increase services, need to state policy of giving intensivitation as organization care toward
paramedics nursing untill paramedics nursing still exist in job.

Next research works
1. Using any objects remain at hospital but is more directed to the various types hospital in east java or on other

provinces in Indonesia. With a sample of research that is paramedics nursing and non-paramedic nursing and
non-paramedics.

2. This research not fills variable stage of turnover/ attention to leave or attention to stay. In suggested that
next research can learn that variables.

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8842

Understandingan alternative approach to paramedic

leadership

JOHNSON, David, BAINBRIDGE, Peter and HAZARD, Wendy

Available from Sheffield Hallam University Research Archive (SHURA) at:

http://shura.shu.ac.uk/22287/

This document is the author deposited version. You are advised to consult the
publisher’s version if you wish to cite from it.

Published version

JOHNSON, David, BAINBRIDGE, Peter and HAZARD, Wendy (2018).
Understanding an alternative approach to paramedic leadership. Journal of
Paramedic Practice, 10 (8), 1-6.

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http://shura.shu.ac.uk/information.html

1

Understanding a New Model of

Leadership

Abstract

Leadership is an essential feature of the life of a paramedic. During incidents, whilst working

with multi-agency colleagues, and within organisations leadership is an expected quality of

all paramedics. Across health and social care organisations leadership is said to be of

pivotal importance to future success. These issues have led to a large investment in

leadership development programmes that organisations are now seeking to justify.

Leadership as a concept is, however, complex and multifaceted. The nature of leadership

has been debated over millennia and still disagreement exists as to how to define it. This

paper utilises Critical Interpretive Synthesis to consider how approaches to leadership have

developed over time. It concludes with a synthesising argument that leadership is a social

construct; as such no single definition will ever be appropriate, however, the four elements

that comprise the leadership equation should be considered if the paramedic leader in

organisations is to be effective.

2

Introduction

Leadership is an essential feature of the life of a paramedic. Paramedics will be expected to

demonstrate leadership during incidents, whilst working with multi-agency colleagues and

within employing organisations. Simply, leadership (however it is defined) is an expected

quality of paramedics, be they in practitioner or management roles.

Leadership is said to be of pivotal importance to the future of health and social care

organisations (Dazi 2008, Ham 2011). Many authors (e.g. Alimo-Metcalf, Alban Metcalf 2006,

Vardiman et al 2006, Anderson et al 2009, Amagoh 2009, Hotho Dowling 2010) have

identified that organisations that are considered to have good leadership thrive, even when

times are difficult, and conversely, poor leadership is an often cited reason for organisational

failure. As a consequence, the need to develop leadership capacity has been identified as

an important issue in organisations across the world. Leadership is, however, a complex

multifaceted concept, which has been subject to much debate over millennia. In spite of this

debate and the development of many models of leadership, disagreement still exists as to

how it should be defined. This article seeks to explore a new theory of leadership that might

help paramedic practitioners, managers and leaders at all levels within the organisation

begin to understand their unique approach to their leadership role, whatever their particular

3

experience and schooling of leadership, and wherever they are placed within the hierarchy

of the organisation.

Approaches to leadership

In current times there appears to be a constant cry for good leaders and for good leadership

to lead us out of our difficulties. As an example, at the 2011 Conservative Party Conference,

David Cameron (2011) stated

“In these difficult times, it is leadership we need, to get our economy moving, to get our

society working. Leadership works”

It is relatively easy to speak eloquently about the merits of leadership; people have been

studying it and attempting to do so for millennia. The difficulty is that whilst leadership is a

concept that most people instinctively understand, it becomes really difficult to closely define

what good leadership actually is or means (Crainer1998). Who decides when, to use

Cameron’s comments, ‘leadership works’? Northouse (2007) suggests that people are

captivated by the concept of leadership. But as they begin to explore this complex and

multilayered phenomenon, they develop their own understanding of what it is, and this

understanding is often really subjective.

In recent times, there has been an exponential increase in research activity into what

effective leadership within organisations is. In 1991 Fleishman et al (1991) identified sixty-

five different classifications of leadership. In 1995 Crainer (Mullins 2007) suggested that four

hundred definitions of leadership existed. Eight years later Bennis and Nanus (2003)

concluded that eight hundred and fifty different classifications had been developed. In 2003,

14,000 books related to leadership were on sale via the on line retailer Amazon.co.uk, by

2009 this had increased to 53,000 (Grint 2010). A similar search in July 2013 revealed that

this total had reached approximately 72,000 books. A scoping search in July 2013 of the

Sheffield Hallam University Library gateway using the word ‘Leadership’ indentified

approximately 1,600,000 items. When filtered to only consider peer reviewed publications,

4

415,000 journal articles were identified. Research into effective leadership appears to have

experienced exponential growth. Simkins (2005 p10) commented that even though defining

effective leadership had proved elusive, ‘some still believe that this holy grail is within our

grasp, or at the least the search for it is not in vain’. Crainer (Mullins 2007p363) warns

however, that so many definitions of leadership can lead to “minefields of misunderstanding”

through which practitioners and researchers must tread carefully. Grint (2010) postulated

that the field had become so complicated that even the concept of leadership was now

contested.

A brief (recent) history

The majority of research studies in the first half of the 20th century were concerned with

attempting to define and refine behaviours, qualities or characteristics of leaders (Avolio

2007). This period of research, sometimes labelled trait theory, sometimes labelled ‘great

man’ theory, is characterised by the belief that leaders are born and not made. The search

was to indentify the characteristics or traits that made great leaders. Large numbers of traits

were identified. The significant problem that Mann (1959) discovered after reviewing all of

the studies conducted between 1900 and 1957 was that the correlation between leadership

and the identified personality variables (or traits) was inconsistent and, significantly, overall

quite low.

A series of models of leadership that fitted into an approach known as Contingency or

Situational Leadership followed. The concept behind these approaches was first identified by

Stodill in 1948. Stodill was engaged in a meta analysis of leadership traits and could not

indentify any significant results. He did, however, identify for the first time that the situation

played a large role in how the leader behaved. Research effort then focussed on validating a

number of contingency and situational modules. The majority of models from this period (a

number still have relevance today) consider that effective leadership is an artefact of the fit

5

between the leader’s characteristics and of the unique situation that they confront (Avolio

2007, Haslam et all 2011). Northouse (2007) suggests that leaders should adapt their style

to meet the needs of the situation.

In 1978 MacGregor Burns developed a new concept of leadership that he called

transformational leadership. A collection of similar transformational approaches emerged

during this time and became known as new paradigm approaches (Alimo-Metcalf, and

Alban-Metcalf 2005). The adaptation of the term transactional leadership also became

common and is considered the antithesis of transformational leadership. McGregor Burns’s

concept gained momentum and in the 1990s was perhaps the most popular and the most

researched of the new paradigm approaches to leadership (Judge and Bono 2000, Alimo-

Metcalf, and Alban-Metcalf 2006).

Transformational leadership was felt to be a leadership style that fitted the needs of the

workforce.(Northouse 2007). Burns wanted to develop a concept that positively linked

leaders and their followers. The aim of his model was to transform people; to help them

become the best that they could become, so that together, the organisation and the people

in it could achieve so much more that had been originally expected. The model included

concern for ethics, standards and satisfying the needs of followers. (Alimo-Metcalf, and

Alban-Metcalf 2005)

Burns also distinguished transformational leadership from transactional leadership.

Transactional leaders rely on what is called the exchange or transaction that occurs between

the leader and the follower. So at a simple level if the follower, working in an organisation,

does what the leader requires of them, they will receive a salary that recognises their

contribution to common goals. This is the transaction or exchange. Burns believed that most

leadership models are transactional in nature. This approach is evident at all levels

throughout all types of organisations. Transactional leadership is often associated with the

term management.

6

Research focussed on assessing the effectiveness of transformational models. As an

example, Alimo-Metcalf and Alban-Metcalf (2005) discovered, following a large study of

public sector organisations in the United Kingdom, that transformational leadership leads to

higher levels of satisfaction, motivation and productivity and lower levels of sickness

absence and employee turnover.

Whilst the popularity of transformational leadership continues, a model of leadership called

distributed or shared leadership has been gathering attention. This, again, is an area of

contested definitions (Currie and Locket 2011). The underlying concept is a recognition that

it is becoming increasingly difficult in complicated multi-skilled environments (like ambulance

services organisations) for a single person to be able to lead on all aspects of the

organisation. The leadership task is distributed or shared with others. To be effective,

distributed leadership is intended to be a whole organisation concept and culture, with all

members of the organisation able to take a lead when required (Hartley et al 2008).

The leadership space has become increasingly complex, increasingly contested and

increasingly noisy. With so many models of leadership, often supported by a strong evidence

base, it is increasingly difficult for practitioners, managers and leaders to understand how

and why they should behave. What is, perhaps, the latest leadership cloak that they should

put on in an attempt to follow the latest leadership fashion or fad? Should they become

transactional, transformational, or distributed?

There is perhaps a need to attempt to cut through this noise, to look for commonalities and

develop a theory that paramedics might find of use; whatever their particular leadership

schooling or approach.

Leaders of the future

Grint (2010) discusses tame and wicked problems in organisations. Tame problems may be

incredibly complex but solutions do exist. Wicked problems tend to have no known answers.

He suggests that leaders of the future will have to face many wicked problems. Handy

7

(1989) suggests we are entering a new era where the only thing that we can be certain of is

that things will change. We can’t anticipate how or when changes will occur only that they

will. He asserts that future leaders need the skills to be ready to adapt to this unknown world.

Drucker reports “We are in one of these great historical periods that occur every 200 or 300

hundred years when people don’t understand the world anymore and the past is not

sufficient to explain the future” (Cameron and Quinn 2011 p1). Watkins et al (2011p9)

suggest leaders will need to find new ways of working with people as they cope with the

“reality that change is continuous relentless and accelerating”. Grint, Handy, Watkins and

Drucker don’t refer to any particular sector, however their words seem to have a particular

resonance when considering the many complex issues that those who work within what has

traditionally been called Ambulance Services face, as we move into an uncertain and

challenging future.

The paramedic leaders of the near future will be dealing with many problems that require

solutions that don’t yet exist. How will we cope with an ageing, better informed, high

expectation, instant messaging society? How will we continue to deliver our high quality

service when faced with what Hawkins and Smith (Chard et al 2013 p23) call “the unholy

trinity of: greater demand for services, higher quality expectations and less resource”? As

such the traditional models that may have been considered the maps for leadership within

Ambulance Services might no longer provide the direction needed.

A literature review utilised an approach called Critical Interpretive Synthesis to look for

commonalities across leadership models. Mays et al (2005) argue that management and

leadership research has many complexities. The real world research environment of

leadership research has been described as messy and inefficient (Edmondson &

McManus2007 p1155). Practitioners within the leadership and management community

have myriad backgrounds and derived knowledge from an eclectic and pragmatic array of

perspectives that might range from sociology and anthropology to economics and statistical

analysis (Easterby-Smith et al 1991, Gray 2009). As a consequence there is not a

consistently agreed approach to research within this field and many sources of legitimate

8

evidence exist that might include quantitative, qualitative and grey literature findings. It is

argued that an effective leadership literature review would need to derive and synthesise

often complex information from multiple sources.

Critical Interpretive Synthesis (Dixon-woods et al 2006) is ideally suited to complex situations

with multiple sources of evidence.

Dixon-Woods et al state that although a number of approaches to enable synthesis of

qualitative data have been developed in recent years, very few methods allow for the

synthesis of evidence regardless of the study type. They believe this approach allows for this.

The Critical Interpretive Syntheses review concluded with a number of what are described as

synthesising arguments.

Synthesising argument 1 – Leadership is a Social Construct

Bass and Bass (2008) argue that we are subjected to leadership influences from birth and

throughout our lives. Our mothers, fathers, extended family, schools, etc all provide early

influences into how we perceive leadership. Our friends, work environment, profession,

colleagues and leaders all continue with this influence as we journey through life.

Social Constructivists believe that truth does not exist independently of human interpretation,

but instead meaning is attributed to an object as a consequence of its integration with the

human world. Crotty (1998 p42) suggested that constructivists believe “meaning is not

discovered but constructed”. A constructivist world is not a static place, it has fluidity to it.

As we engage with the world we make sense of the concepts and objects that we encounter.

That sense making is influenced by our experiences. It may be our culture, our values, our

social class, it may be our profession, our organisation or our experience of leaders, but

whatever it is, the sense we make of an object like leadership will be shaped by our

experiences up until that time. This sense making may continually evolve as our exposure

and experience to the object increases.

9

There are many models and ways in which leadership can be described. Researchers,

academics and philosophers have sought an answer to this difficult, complex and multi

faceted phenomenon and, despite over three thousand years of questioning and research, it

still appears to defy definition (Grint 2010 Crainer 1998). Northouse (2007p2) suggests that

although we “intuitively know what leadership is”, when attempts are made to truly define it,

many different meanings emerge. Hernandez et al (2011) describes how although many of

the models that have been developed have helped our understanding we are still striving to

identify new and disparate approaches.

It is perhaps time to call off the search for Simpkin’s “Holy grail” (2005 p10). There is no one

right answer or approach; leadership is a social construct and effective leadership is

constructed by our understanding of ourselves, the world that we live in, and the values and

experiences that we have had that have led us to become unique individuals. This will

change as our experiences change our perception of leadership in organisations. As Grint

(2005 p1471) suggests “the book is never closed but always open to contestation.”

Synthesizing Argument – The Leadership Equation

Turnbull-James (2011p7) questions the popular view that leadership is beyond definition.

She reports that, the field has unified behind a basic assumption for some time, and “in its

simplest form leadership is a tripod” made up of the leader, the follower and the goal that is

to be attained. Others have recognised this position, as examples, Clark and Clark (1996

p25) didn’t agree with what they describe as the “common perception of the elusive nature of

leadership”. Their definition suggested that leadership is an activity, in which “leaders and

followers willingly subscribe to common purposes and work together to achieve them “.

Northouse (2007) defines leadership as “a process whereby an individual influences a group

of individuals to achieve a common goal”

Avolio (2007) suggests that the context in which the leader operates is an important

consideration to their approach to leadership.

10

The four common elements that contribute to the majority of leadership models are

considered to be the leader, the follower, the operating context and common goals. These

could be considered as a unique equation.

Whatever model or approach to leadership that holds sway at any particular time, it appears

it is always a balance or a rebalance of the four elements of the leadership equation.

The menu of leadership styles has become rich and diverse. Practitioners may choose from

an eclectic array of approaches, many of which have a supporting evidence base. If there is

no clearly defined right approach, how then can effective choices be made? The leadership

equation allows for multiple realities of leadership. It asks leaders to consider the best way

for them to lead, regardless of the current fashion of leadership thinking. Leaders, at any

level in an organisation, should pay attention to the factors that contribute to the elements

that form the leadership equation. It is suggested that if all of the elements have been

scrutinised, analysed and uniquely considered by the individual leader and a balanced view

arrived at, the leader will have the best chance of success.

Conclusion

Leadership is a complex subject that has been studied extensively over a long period of time.

Its importance to effective and efficient organisations has been considered and restated

many times. This has led to a wealth of research seeking to identify the right approach to

successful leadership. Despite much energy and activity no single approach has been

indentified that provides an answer to this question, instead a wide and eclectic array of

Understanding
The Leader

Understanding
The followers

Understanding
Common

Goalls

Understanding
The Context

Understanding
Effective

Leadership

11

approaches is proposed. Through a critical interpretive synthesis of literature, a synthesizing

argument that suggests that leadership is a social construct has been propagated. There will

be no single right approach that is appropriate for all (Allio 2009). The literature however,

does suggest that, fundamentally, each leadership model contains a balance of four

elements the leader, the follower, common goals and the situation. In order for individual

paramedic leaders to be successful, consideration has to be given to how each of the

elements relate to each other. If the paramedic leader is able to do this, regardless of the

style that they adopt, it is suggested that they will be successful.

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O P E N A C C E S S Research article

Utilization of prehospital emergency
medical services in Saudi Arabia: An
urban versus rural comparison
Ahmed Ramdan M Alanazy, Stuart Wark, John Fraser, Amanda Nagle

ABSTRACT

Background: There is limited research outside the USA, Europe, or Australia on the capacity, efficiency,

and development of prehospital emergency medicine services (EMS) between urban and rural

areas.

This study aimed to examine the usage of prehospital EMS across rural and urban areas in Riyadh

region in the Kingdom of Saudi Arabia.

Methods: A random sample of 800 (400 urban and 400 rural) emergency patient records from the

Saudi Red Crescent Authority EMS was collected. The following variables were analyzed: patient

demographics, clinical characteristics, length of hospital stay, and length of intensive care unit (ICU)

stay.

Results: A skewed distribution was noted with respect to sex, i.e., 559 men versus 241 women. Rural

patients were younger (42.75 vs. 39.72 years) and had significantly longer hospital (15 days versus

9 days) and ICU (5 days versus 2 days) stays than urban patients following transportation. All injury

types were comparable, except for head injury, which was higher in the rural group than in the urban

group. Advanced treatment and trauma transport were more often used in rural areas than in urban

areas.

Conclusions: In this study, rural EMS users were more likely to experience trauma-related incidents that

necessitate EMS transportation, while medical reasons were more common among urban EMS users.

Moreover, men used EMS at much higher rates than women and were more likely to be transported to

the hospital following a call-out.

Keywords: Rural; Urban; Emergency Medical Services; Saudi Arabia; Riyadh

Cite this article as: Alanazy ARM, Wark S, Fraser J, Nagle A. Utilization of prehospital emergency
medical services in Saudi Arabia: An urban versus rural comparison, Journal of Emergency
Medicine, Trauma & Acute Care 2020:9 http://dx.doi.org/10.5339/jemtac.2020.9

http://dx.doi.org/
10.5339/jemtac.2020.9

Submitted: 20 May 2020
Accepted: 21 September 2020
ª 2020 Alanazy, Wark, Fraser,
Nagle, licensee HBKU Press. This is
an open access article distributed
under the terms of the Creative
Commons Attribution license CC BY-
4.0, which permits unrestricted use,
distribution and reproduction in any
medium, provided the original work
is properly cited.

School of Rural Medicine, Faculty of

Medicine and Health, University of New

England, Australia

*Email: aalanazy@myune.edu.au

INTRODUCTION

For a patient requiring urgent medical assistance, due to either traumatic injury or acute illness, one of

the most significant factors affecting their short- and long-term health prognosis is time.
1
In particular,

the time period before a patient starts receiving healthcare support, usually on site from an emergency

medicine services (EMS), is considered a critical aspect of improving mortality rates and reducing both

the magnitude and longevity of illness or incapacitation of an individual.
2
Similarly, the quality of EMS

support, both initially and then during transportation to a clinical setting, can influence patient

outcomes.

While there is existing research on the availability of EMS in different countries, there is less

consistent evidence on the capacity, efficiency, and development of prehospital EMS structures across

disparate geographic locations. However, some studies have reported a significant difference in EMS

services between urban and rural areas within countries.
3,4

A recent systematic review concluded that

EMS in rural areas were more likely to have longer response times, transport times, prehospital times,

and on-scene times than urban areas. In addition, almost all relevant research was undertaken in the

USA, Europe, or Australia.
5
As a simple example of how this difference manifests in patient outcomes,

Jennings et al.
6
noted that the survival rate of patients following an emergency cardiac event was

considerably higher in urban areas than in rural areas. Other studies have found a significant difference

between urban and rural models as regards response and time transfer and that urban EMS are

generally associated with enhanced performance measures, which in turn increased the survival rates

of patients, compared with rural EMS.
7,8

This study aimed to establish a general picture of patients’ usage of prehospital EMS within the

Riyadh region in the Kingdom of Saudi Arabia, with a specific focus on any variation in patient

presentation between urban and rural locations. A literature search did not reveal any research in

Riyadh that specifically examined this issue, and only a few studies were conducted outside the USA,

Europe, and Australia that compared urban versus rural EMS outcomes. This paper is part of a larger

research project examining issues associated with the performance of EMS in rural and urban locations

within Saudi Arabia.

METHODS

Study design and setting

A cross-sectional study was conducted using emergency patient records (EPRs) collected over a period

of one year from January 1, 2017, to December 31, 2017, by the Saudi Red Crescent Authority EMS in the

Kingdom of Saudi Arabia. The Saudi Red Crescent Authority started providing EMS in the Kingdom in

the early 1930s, and remains the primary provider of EMS in the Kingdom.
9
Ethical approval was

obtained from the University of New England’s Human Research Ethics Committee, Saudi Arabia

Ministry of Health Ethical Committee, King Abdelaziz Medical Cities Ethical Committee, and Saudi Red

Crescent Authority.

The geographic setting for this study was the Riyadh region in the Kingdom of Saudi Arabia. Riyadh is

one of the 13 administrative regions and is located approximately in the center of the country. Initially,

the project planned to focus on data from the Makkah administrative region, as it has the largest

population base and highest EMS transportation rates. However, following a review of the region’s

general demographic data, it was not considered representative of all of Saudi Arabia. It has significant

religious events (pilgrimage) that result in large numbers of international visitors; the General Authority

for Statistics noted an annual 1.8 million visitors to the region.
10
Riyadh, the region with the second

highest number of transported cases, was then reviewed and ultimately selected as the data source.
11

Riyadh region has an estimated population of eight million people, who live across a geographic area

of 400,000 km
2
, and includes the capital city of Saudi Arabia, also called Riyadh. In accordance with

the geographic classification provided by the Saudi Red Crescent and use of EPR forms, individuals

residing in Riyadh City were considered ’urban,’ while all other areas of Riyadh region were defined as

‘rural.’

Data collection and analysis

A random sampling method was employed to select EPRs included in this study. While it would have

been preferable to include all EPRs, there were no comprehensive electronic datasets of patient records

available; therefore, each hard copy was physically read and data manually transcribed. To ensure a

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Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

suitable sample, a sample size was calculated prior to the commencement of the project
12
and was

determined to be 392 EPRs. Prior to data collection, 400 EPRs would be selected from urban areas and

400 EPRs would be selected from rural areas, resulting in a total sample of 800.

The 800-item dataset was sourced from the hardcopy EPRs created following an EMS response to

each emergency call-out. EPRs were stored at the Saudi Red Crescent central office in Riyadh City,

including all forms submitted from each of the 78 EMS stations (30 rural and 48 urban sites) in Riyadh

region. The files were selected using a computer-generated random number list, with a supervisor from

Saudi Red Crescent, and all records that were randomly selected were then de-identified. These files

were then provided to the lead author, and data were transcribed into IBM SPSS Statistics for Windows

version 25 (IBM Corp., Armonk, NY, USA). Simple descriptive statistics were used to describe the cohort

profile, while Chi-square tests were used for comparison purposes.

The following variables were collected from the EPRs:

1. Patient demographics

Demographic data included age, sex, and residential location (rural or urban).

2. Clinical characteristics

Clinical characteristic data included the on-scene outcome (treatment, nontreatment, transfer to

hospital), type of on-site care provided (airway, breathing, circulation, extrication or immobilization),

general classification of illness/injury (medical or trauma), and specific classification of illness/injury

(head injury, dizziness, etc.).

3. Length of hospital stay

The length of stay in hospital was noted in whole days.

4. Length of intensive care unit (ICU) stay

The length of stay in an ICU was noted in whole days.

RESULTS

Differences in patient demographic data by sex

On initial inspection, there was a clear skew in data with respect to sex. Overall, the sample was

composed of 559 men and 241 women. There was also a difference between sexes in terms of age,

where female EMS users (41.2 years) were slightly older on average than male EMS users (39.72 years).

Basic support on the scene was far more common than advanced treatment for both sexes, with 551

men and 237 women receiving basic support in contrast to just eight male EMS users and four female

EMS users receiving advanced treatments. There were 18 male deaths and three female deaths on

scene. For male EMS users who were transported to a hospital from the scene, the reasons for

transportation were evenly divided, with 282 for medical reasons and 277 for trauma reasons. This

pattern was quite different for female EMS users, with 189 transports for medical reasons and 52 for

trauma reasons, which represented a ratio of 3.6 medical cases to every one trauma case. Table 1

provides a summary of the key patient data for both male and female EMS users. The incident type ‘no

medical care provided’ refers to situations in which patients were transferred between locations for

Table 1. Key patient data for sex

Variables Male Female Sig. (p values)

Patient taken from scene to hospital Yes 70 32 0.046*
Incident type No medical care provided 18 6 0.578

Fracture/laceration 94 17 ,0.001*
Head-neck injury 85 15 ,0.001*
Chest injury 22 3 0.045*
Dizziness 61 41 0.018*
Wound/burn 37 9 0.108
Cardiorespiratory 22 10 0.887
Gastrointestinal 25 14 0.420
Neurological 14 13 0.830
Respiratory 34 19 0.347
Others 147 94 ,0.001*

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Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

treatments, such as for hemodialysis, and where the EMS was not required to provide any medical

interventions.

Significant differences were noted in EMS usage between male and female EMS users. Male EMS

users are more significantly likely than female EMS users to be taken to a hospital following an EMS

call-out or to experience a fracture/laceration, head–neck injury, chest injury, or dizziness. Data for the

incident type ‘others’ was also statistically significant, but the lack of details provided in the EPRs on

this category makes any analysis attempts meaningless.

Differences in patient demographic data by location

The sample was deliberately composed of an equal number (n ¼ 400 each) of urban and rural

residents. The urban group was composed of 264 (66%) male EMS users and 136 (34%) female EMS

users, while the rural group included 295 (73.8%) male and 105 (26.3%) female EMS users. The mean

age of the urban group was 42.75 years, while this dropped to 39.72 years for the rural cohort.

The number of advanced treatments was small overall when considered by geographic location. In

total, 398 urban and 390 rural residents received basic treatment on scene, compared with just two

urban and 10 rural people who received advanced treatment. The number of deaths on scene (n ¼ 13)

was higher in rural areas than in urban ones (n ¼ 8), but the overall death rate was low. Medical

reasons were more common reasons for transportation to hospital for urban EMS users (259 medical

versus 141 trauma), which represents a ratio of 1.8 medical case for each one trauma case. However,

this difference was smaller in rural locations (212 to 188), with a ratio of 1.1 medical case to one trauma

case. Key demographic data are outlined in Table 2. Two significant differences were found between

urban and rural EMS users: rural residents were more likely to experience fractures/lacerations, while

urban residents were at greater risk of wounds/burns.

Clinical characteristics: urban versus rural

A further analysis was undertaken to examine differences in the clinical characteristics of urban versus

rural residents. Table 3 summarizes the difference in the presentation of body injury or illness

according to the patient’s geographic location. Head, face, and extremity injuries were more common in

rural areas, while chest, abdomen, and back injuries were more common in urban areas; however, no

significant difference was found between the groups, except for head injuries, which were higher in

rural than in urban areas ( p ¼ 0.018). Otherwise, no other significant differences were observed based

on injury type with respect to location.

The injury type, as opposed to the presentation of injury or illness, is outlined in Table 4. The patient

outcome, in terms of the length of stay either in a hospital or an intensive care unit, is also noted. The

lengths of stay for patients transported by EMS specifically into an ICU and generally in hospital are

both significantly shorter in urban than in rural areas (p , 0.001).

No significant difference was found between urban and rural patients in terms of the provided care

(Table 5) for airway treatment, breathing treatment, and extrication and immobilization treatment.

However, a significant difference was found for circulation treatment, with urban patients more likely to

receive this treatment.

Table 2. Key patient data for urban and rural areas

Variables Urban Rural Sig. (p values)

Patient taken from scene to hospital Yes 43 59 0.114
Incident type No medical care provided 15 9 0.214

Fracture/laceration 45 66 0.032*
Head-neck injury 43 57 0.134
Chest injury 15 10 0.310
Dizziness 53 49 0.672
Wound/burn 31 15 0.015*
Cardiorespiratory 17 15 0.718
Gastrointestinal 20 19 0.870
Neurological 15 12 0.557
Respiratory 27 26 0.887
Others 119 122 0.817

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Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

DISCUSSION

Prehospital EMS are a critical element of modern health systems, and their performance is a vital

component of any care model designed to improve patient outcomes associated with traumatic

injuries and time-sensitive diseases.
1
However, there is still a significant need for current research to

provide information on the strengths and weaknesses of prehospital EMS and particularly in relation to

key demographic differences across rural and urban areas. A recent systematic review noted that

almost all research undertaken in this area has focused on the USA, Europe, or Australia.
5
The

likelihood of service discrepancies between rural and urban settings is arguably even higher in lower

resourced countries due to the inaccessibility of health services in rural areas, with identified key

factors potentially affecting patient outcomes.
13

The present study examined a random sample of 800 EMS users within the Riyadh region in the

Kingdom of Saudi Arabia. The purpose of this study was to establish a profile of both urban and rural

EMS patients and to compare key demographic variables so as to identify any differences in outcomes.

Table 4. Injury type and length of stay in hospital or intensive care unit

Variable Urban Rural Sig. (p values)

Length of stay in hospital (days) 9 15 ,0.001*
Length of stay in ICU (days) 2 5 ,0.001*
Problem type No medical care provided 15 9 0.214

Fracture/laceration 45 66 0.03*
Head-neck injury 43 57 0.134
Chest injury 15 10 0.310
Dizziness 53 49 0.672
Wound/burn 31 15 0.150
Cardiorespiratory 17 15 0.718
Gastrointestinal 20 19 0.870
Neurological 15 12 0.557
Respiratory 27 26 0.887
Others 119 122 0.817

Table 5. Patients’ treatment and progression frequency

Items Frequency Frequency Sig. (p values)

Urban Rural

Provide airway treatment Yes 16 15 0.999
No 384 385

Provide breathing treatment Yes 169 167 0.943
No 231 233

Provide circulation treatment Yes 147 111 0.008*
No 253 289

Provide extrication and immobilization treatment Yes 96 103 0.624
No 304 297

Table 3. Presentation of injury or illness

Variables Frequency Sig. (p values)

Urban Rural

Head injury/illness Yes 43 67 0.018*
No 357 333

Facial injury/illness Yes 12 20 0.206
No 388 380

Chest injury/illness Yes 20 18 0.868
No 380 382

Abdominal injury/illness Yes 20 16 0.609
No 380 384

Back injury/illness Yes 40 35 0.628
No 360 365

Extremity injury/illness Yes 76 94 0.142
No 324 306

Page 5 of 7

Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

Initial examination indicated a skew in data with respect to sex, so data analyses were performed

separately with respect to both sex and geographic location. The findings associated with these

analyses are discussed below.

Differences by sex

The reasons for transport from the scene were categorized as either medical or trauma. The data showed

nearly equal numbers for male EMS users, with 282 for medical reasons and 277 for trauma reasons.

However, this pattern was quite different for female EMS users, with 189 medical reasons and 52 trauma

reasons. The reasons for this skewness are not possible to determine accurately in a cross-sectional

study; however, it is consistent with a previous study in Turkey showing that men use EMS at a higher rate

than women,
14
although this finding contrasts with those in countries such as Australia and USA where

an equal number of men and women utilize EMS.
15
Compared with previous studies, the percentage of

using the ambulance according to sex were almost the same without huge differences.
16–18

The precise

reasons are impossible to determine definitively, but it is hypothesized that men in Saudi Arabia are

likely to have high exposure to potential traumatic events arising from high-speed vehicular accidents or

higher-risk workplaces.
19
In this study, there were 18 male deaths and three female deaths on scene, and

this difference was believed to be due to men’s higher risk for significant trauma.

A difference was found between men and women with respect to the reason of transport to a hospital

from the scene. For men, there was little distinction between those transported for medical reasons,

such as illness and injury arising from trauma. However, over 3.5 times as many women were

transported following a medical event than following a traumatic event. Men were also more likely than

women to be taken to hospital and to have fractures or lacerations, head–neck injuries, or chest

injuries. These differences are believed to arise from the fact that women have low exposure to

potential risk factors that may result in traumatic injury, and there is little that EMS could do to

proactively prevent the occurrence of such injuries in men. However, further research into these

observed differences is recommended to better understand whether EMS needs to change on-scene

management and transportation to address these issues.

Differences by geographic location

Our data showed that medical problems were nearly twice as common as trauma when considering the

reasons for transportation to hospital for urban EMS users. However, this difference was much smaller

in rural areas than in urban areas and was close to parity with 1.1 medical problems for every trauma. As

noted above in the section regarding sex differences, this difference was considered largely due to the

increased risks of experiencing traumatic injuries arising from high-speed vehicular accidents or from

farming or industrial workplaces. While there is limited research data from Saudi Arabia, studies

conducted in USA and Sweden indicate that rural trauma cases often result in more severe injuries than

urban cases.
20,21

The number of deaths on scene (n ¼ 13) was higher in rural than in urban areas

(n ¼ 8), but the overall numbers were low.

Although the numbers were low, rural residents were significantly more likely to have longer hospital

or ICU stay after being transported by EMS. This finding is inconsistent with those in other countries,

with studies in the USA and Europe not reporting any significant differences in ICU and hospital stay

between rural and urban EMS users.
22,23

It was not possible to determine the severity of injury or illness

from the EMR forms; therefore, comparisons of whether rural patients had more serious health issues

than urban patients could not be established. This issue requires additional exploration to consider

whether rural factors, such as workplace exposures, may explain this difference. However, rural EMS

may have lower levels of training and/or availability of equipment,
1–5

and this could account for some

of the variance; thus, further research is required to examine this issue in more detail.

Another issue recommended for follow-up research is to evaluate whether there are any differences

in response time and on-scene time for urban and rural EMS users, as this has been observed both in

Saudi Arabia and in other countries.
5
The present data showed that rural people were five times as

likely to receive advanced treatment, although the overall numbers were small. In other settings, any

delays to the commencement of life-saving treatments, such as those that are likely to occur after

significant trauma, may increase the need for advanced on-site treatment and lead to worse overall

health outcomes for patients.
1,2,6–8

In rural areas, geographic distances that will naturally result in

longer response times and longer subsequent transportation times to a major healthcare setting are

key factors that require more detailed analysis within Saudi Arabia.

Page 6 of 7

Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

LIMITATIONS

This cross-sectional study examined a random sample of 800 cases in the final dataset. While this

sample size is sufficient with respect to the initial power calculation, it would have been desirable to

include every EMS case in the Riyadh region. As EMS records were not electronic, data were manually

extracted from original hard copies, and collating all such data was beyond the scope of this project.

CONCLUSIONS

Analysis of this cross-sectional dataset by both geographic location and sex identified a number of key

issues. One of the main differences was the greater likelihood of rural EMS users to experience trauma-

related incidents that necessitate EMS transportation, while medical reasons were more common

among urban EMS users. Moreover, men used EMS at much higher rates than women and were more

likely to be transported to hospital following a call-out. Exploring the reasons for these findings was

beyond the scope of the current study; thus, further investigation is required to better understand the

observed outcomes.

Conflict of interest

There were no conflicts of interest, perceived or otherwise. There is no funding to declare.

REFERENCES

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[4] Mihalicz D, Phillips L, Bratu I. Urban vs rural pediatric trauma in Alberta: where can we focus on prevention? J Pediatr
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[6] Jennings PA, Cameron P, Walker T, Bernard S, Smith K. Out-of-hospital cardiac arrest in Victoria: rural and urban
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[7] Gonzalez RP, Cummings G, Mulekar M, Rodning CB. Increased mortality in rural vehicular trauma: identifying
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[8] Newgard CD, Fu R, Bulger E, Hedges JR, Mann NC, Wright DA, et al., Evaluation of rural vs urban trauma patients served
by 9-1-1 emergency medical services. JAMA Surg. 2017;152(1):11–18.

[9] AlShammari T, Jennings P, Williams B. Evolution of emergency medical services in Saudi Arabia. J Emerg Med Trauma
Acute Care. 2017; 4:1–11.

[10] General authority for statistics. Saudi Arabia health statistics. https://www.stats.gov.sa. Accessed April 12, 2020.
[11] Saudi Red Crescent Authority. Saudi Red Crescent Authority Statistics. https://www.srca.org.sa/en/Statistics/open-

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[12] Kadam P, Bhalerao S. Sample size calculation. Int J Ayurveda Res. 2010; 1(1): 55–57.
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[16] Toloo S, Fitzgerald G, Rego J, Tippett V, Quinn J. Age and gender differences in ambulance utilisation in Queensland.

https://eprints.qut.edu.au/40191/. Accessed 2 April, 2020.
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statistics and regression analyses. West J Emerg Med, 2016;17(1):39.
[18] Knowlton A, et al., Patient demographic and health factors associated with frequent use of emergency medical

services in a midsized city. Acad Emerg Med, 2013;20(11):1101–1111.
[19] World Bank. Gender Portal Data – Saudi Arabia – Labor Force. http://datatopics.worldbank.org/gender/country/saudi

-arabia. Accessed March 5, 2020.
[20] Beillon L, Suserud B-O, Karlberg I, Herlitz J. Does ambulance use differ between geographic areas? A survey of

ambulance use in sparsely and densely populated areas. Am J Emerg Med, 2009;27(2):202–211.
[21] Newgard C, et al., Evaluation of rural vs urban trauma patients served by 9-1-1 emergency medical services. JAMA

Surgery, 2017;152(1):11–18.
[22] McCowan C, Swanson E, Thomas F, Handrahan D. Outcomes of blunt trauma victims transported by HEMS from rural

and urban scenes. Prehosp Emerg Care, 2007;11(4):383–388.
[23] McGuffie A, et al., Scottish urban versus rural trauma outcome study. J Trauma Acute Care Surg, 2005;(3):632–638.

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https://www.stats.gov.sa

https://www.srca.org.sa/en/statistics/opendata

https://www.srca.org.sa/en/statistics/opendata

https://eprints.qut.edu.au/40191

http://datatopics.worldbank.org/gender/country/saudi-arabia

http://datatopics.worldbank.org/gender/country/saudi-arabia

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Leading on the edge: The nature
of paramedic leadership at the front
line of care

Danielle Mercer

Arlene Haddon

Catherine Loughlin

Background: Health care organizations are considered complex systems that represent both formal leadership as
well as more informal and shared leadership models. Implementing these models is essential for optimizing care
and patient outcomes. The paramedic profession specifically, although considered informally, leads out of hospital
patient care.
Purpose: To date, few empirical studies investigate shared leadership in health care settings. In paramedicine
specifically, studies of leadership are scarce, despite paramedics’ essential role in leading on the front lines of care.
Using an exemplar of paramedics, we examine what it means to informally lead on the front lines of patient care
with the emphasis on paramedics responding out of hospital.
Methodology: We employed a qualitative, semistructured interview methodology with 29 paramedics from a
group of companies in central/eastern Canada to explore the conditions and practices surrounding shared
leadership.
Findings: Paramedics argue that, despite their job title, they classify themselves as informal leaders who share the
leadership role. More specifically, the paramedics discuss the precursors, practices, and structural conditions
surrounding shared leadership within the realm of emergency medical services. They note that they often face
out-of-hospital care without a formal manager, requiring them to collectively lead. The leader will shift in times of
urgency, and this is contingent on their skills and competence. Furthermore, managers routinely called upon
paramedics to lead in their absence.
Practice Implications: It is shown here that, although informally enacted, paramedics view leadership as a necessary
competency for clinical practice. We argue that leadership development of paramedics must begin during their
formal education and training as part of the core curriculum. As well, direct managers can promote an environment
of shared leadership and encourage paramedics to practice leadership with quality of patient service in mind.

Key words: health care, informal leadership, paramedics, shared leadership

Danielle Mercer, MBA, is PhD Candidate, Department of Management, Saint Mary’s University, Nova Scotia, Canada. E-mail:
daniellemariemercer@yahoo.ca.
Arlene Haddon,1 PhD, Department of Management, Saint Mary’s University, Nova Scotia, Canada.
Catherine Loughlin, PhD, is Associate Dean, Research & Knowledge Mobilization, Department of Management, Saint Mary’s University, Nova
Scotia, Canada.
The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.
1These data were collected by the second author for her PhD dissertation before her untimely death because of cancer. We hope we have done justice
to her memory in our write-up of her work.

DOI: 10.1097/HMR.0000000000000125

Health Care Manage Rev, 2018, 43(1), 12Y20
Copyright B 2018 Wolters Kluwer Health, Inc. All rights reserved.

12 JanuaryYMarch & 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

A
radio transmission urges all emergency medical
services (EMS) to respond to a call for a multiple
vehicle crash. Within seconds, ambulance sirens

are roaring to the scene of the accident. Paramedics are
the first to arrive and must assess the situation as quickly
as possible. One of the paramedics who was quite senior
says, Bthey were basically able to take themselvesIand
come up with the bigger plan (Respondent 13).[ The
paramedics broke into subgroups and began treating the
patients. A paramedic realized they were missing a vital
piece of equipment and was distraught; another paramedic
said, Bok we’ll move on to plan B and use the equipment
when we get it (Respondent 6).[ Throughout the call,
there are countless situations where different paramedics
step forward to influence the group and then step back.
Some paramedics had very little on the job experience,
others had over 20 years, and still others had additional
formal training, but none of these paramedics had an official
position of authority/leadership. Despite this, paramedics’
leadership composition shifted repeatedly throughout the call.

As evident in the compilation of interview responses
above (i.e., Interview responses 6 and 13), paramedics rotate
through various roles to ensure the best standard of patient
care. Each call is unique, uncertain, and often chaotic,
requiring paramedics to be able to assess and make decisions
instantly and, more importantly, to engage in interde-
pendent and influential relationships. The paramedic field
is a vital component of the health care sector and often
forms the gateway into the hospital system for victims of
illnesses and accidents (Patterson, Probst, Leith, Corwin, &
Powell, 2005). Traditionally, leadership theories have
focused primarily on a management paradigm and examined
the skills, traits, and actions of a sole leader in a formal
position of authority (Ensley, Hmieleski, & Pearce, 2006).
More recently, distributed models of leadership (e.g., in-
formal or shared leadership) are also being examined, and
the interactions of multiple individuals (Yammarino &
Dansereau, 2008) who emerge and collaborate as leaders
are both formally and informally evaluated. Health care
organizations specifically are complex systems that repre-
sent both formal and traditional leadership as well as the
more informal and shared models. Downey, Parslow, and
Smart (2011) stated:

Every [healthcare] facility and unit has a formal
organizational chart that delineates responsibilities
and identifies the chain of command. However, the
manner in which work is truly accomplished often
follows an undocumented and unacknowledged
path, guided byIthe informal leaders. (p. 518)

At the core, health care represents bureaucratic and
topYdown leadership (Penprase & Norris, 2005). However,
health care professionals (e.g., paramedics, nurses) on the

Bfront lines[ are often given the Bflexibility[ to enact in-
formal leadership for the purpose of patient care.

To date, there are few empirical studies that examine
informal and shared leadership models within health care
settings (e.g., Boak, Dickens, Newson, & Brown, 2015;
Chreim, Langley, Comeau-Vallee, Hug, & Reay, 2013).
However, there have been calls for the implementation and
practice of shared leadership models in organizations in
general (e.g., Kokolowski, 2010) and health care specifi-
cally (e.g., Weberg, 2012). We argue that, in investigating
the presence of shared leadership of health care pro-
fessionals, paramedics are a prime exemplar because they
respond on the front lines without a formal manager and
lead out-of-hospital patient care (Stanley, Cuthbertson, &
Latimer, 2012). Furthermore, studies of leadership related
to paramedics are scarce despite their essential role in
ensuring emergency care standards.

The purpose of this study is to examine what it means to
informally lead on the front lines at the point of care with
an emphasis on paramedics responding out of hospital. Our
objective was to understand the conditions and practices
surrounding shared leadership using a sample of health care
professionals who are not formally classified as leaders. To
capture this phenomenon, qualitative, semistructured
interviews took place with paramedics in an emergency
response system in central and eastern Canada.

Theoretical Framework

Shared Leadership Models

The roots of shared leadership models are unknown, but
theoretical contributions in the leadership literature began
appearing in the mid-1990s (Miller, Walmsley, & Williams,
2007). There are several notable conceptualizations of
unconventional and shared leadership models including
distributed leadership (Bolden,2011),informal leadership (e.g.,
Downey et al., 2011), collective leadership (Denis, Langley,
& Sergi, 2012; Friedrich, Vessey, Schuelke, Ruark, &
Mumford, 2009), collaborativeleadership (Rosenthal,1998),
and emergent leadership (Beck, 1981). Inherent in all of
the above studies is the view that multiple individuals are
participating in leadership (Contractor, DeChurch, Carson,
Carter, & Keegan, 2012). According to Bolden (2011),
shared leadership appears to be the most commonly used
conceptualization for studies within health-related journals.

The most commonly cited model of shared leadership
was developed by Pearce and Conger (2003) as Ba dynamic,
interactive influence process among individuals in groups
for which the objective is to lead one another to the
achievements of group or organizational goals or both[
(p. 1). Pearce (2004) extended the definition to being
characterized by the Bserial emergence[ of leadership by

Leading on the edge 13

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

two or more team members. There have been several
other contributions in defining shared leadership (e.g.,
Yammarino, Salas, Serban, Shirreffs, & Shuffler, 2012),
and all discuss in one form or another that the concept is
represented by all team members (e.g., Carson, Tesluk, &
Marrone, 2007; Ensley, Pearson, & Pearce, 2003) both
informally and formally (Yammarino et al., 2012) who
emerge as leaders when their knowledge is required (Bergman,
Rentsch, Small, Davenport, & Bergman, 2012; Yammarino
et al., 2012) and have the capability to influence and direct
team members to maximize team effectiveness (Carson
et al., 2007; Pearce, 2004). Shared leadership is interactive,
equal and/or unilateral (Yammarino et al., 2012, p. 390),
and interdependent between peers (Fletcher, 2004).

Non-Health-Care Sectors

Initial empirical research on shared leadership in the orga-
nizational team-based literature found that it is an important
predictor of team processes and outcomes (Bergman et al.,
2012), positive team functioning (Bergman et al., 2012;
Pearce, 2004), team performance (Ensley et al., 2006), and
team effectiveness (Ensley et al., 2003; Pearce & Sims, 2002).
Wang, Waldman, and Zhang (2014) conducted a meta-
analytic study of shared leadership and team effectiveness
using 161 articles and found an overall positive relationship
between the two constructs. More importantly, the authors
found that what is shared among team members is a pre-
dictor of team effectiveness (i.e., the sharing of leadership
roles focused on change processes).

Other empirical studies have focused on the antecedents
that allow shared leadership to emerge or exist. For example,
Carson et al. (2007) examined the shared leadership of
59 Masters in Business Administration consulting teams
and concluded that there are certain antecedent conditions
for shared leadership to arise within a team environment.
These precursors for shared leadership include the team’s
internal environment (i.e., a shared purpose, social support,
voice) and coaching by an external leader. Similarly, Small
and Rentsch (2010) investigated the antecedents and out-
comes of shared leadership in relation to team performance.
Usingundergraduate business teams,the authors conducted
a longitudinal study using social network analysis and found
that not only was shared leadership positively related
to team performance but also team collectivism (i.e., Ba
person’s inclination towards group interests as opposed to
personal pursuits[ [Small & Rentsch, 2010, p. 205]) and
trust increased shared leadership over time.

Health Care Sector

Recent advances in leadership theories have called for the
examination of leadership as a collective and shared process
that permeates through all levels of health care organiza-
tions (i.e., Shared Leadership for Change, The Health

Foundation UK; LEADS Collaborative, Canadian College
of Health Leaders). Preliminary studies discuss the char-
acteristics of informal and shared leadership and improve-
ments in patient outcomes (i.e., Boak et al., 2015) and the
boundaries surrounding areas conducive to shared versus
formal leadership (Chreim et al., 2013).

A few studies have attempted to operationalize shared
leadership within the realm of health care. Downey et al.
(2011) conducted informal interviews with nurse managers
in acute care settings to develop components of informal
leadership. The authors found that the key characteristics
that define informal leadership include the ability to com-
municate, building strong relations, and actively listening
aswellasspeakingout.Similarly,Milleretal.(2007)soughtto
examine the outcomes of encouraging shared leadership.
Using six teams from diabetes clinical networks (as part of the
Health Foundation’s UK Shared Leadership for Change
Initiative), Miller et al. found that individuals encouraged
to practice shared leadership felt empowered to take on more
responsibility for patient care, were more willing to stand up
for what they saw as effective patient care, and were more
confident to act as leaders. Specific to the paramedic field,
we were able to find one published empirical article (i.e.,
Stanley et al., 2012) that addressed (informal) clinical
leadership qualities and characteristics of paramedics. Re-
spondents stated that their paramedic role allowed them to
engageinleadership becausethey had theabilityto influence
others, were informally mentors, and saw themselves as
setting high standards regarding out-of-hospital care.

Other studies suggest that the role of hierarchical
structure may hinder or support shared leadership practices
in health care. According to Martin and Waring (2013),
managerial hierarchies and institutional structures and
norms constrain leadership practices of those not in formal
management positions. In an effort to alleviate this con-
straint, other researchers have argued for boundary condi-
tions surrounding formal and shared leadership. Opening
boundaries that allow skill sharing, empowerment, collab-
oration, and decision making and closing boundaries related
to the scope of health care practices and specialized tasks
(Chreim et al., 2013). Boak et al. (2015) have argued for a
Bhybrid[ leadership approach between management and
professionals whereby some leadership functions are retained
by management but those related to patient outcomes are
shared among the team. The current study extends shared
leadership research by exploring the precursors, practices,
and structural conditions that allow such models to flourish.

Methods

Sample

To explore our research topic, we utilized a qualitative in-
terview technique. We conducted semistructured interviews

14 Health Care Management Review JanuaryYMarch & 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

with 29 paramedics from EMS in central and eastern
Canada. Qualitative research aims to understand the lived
experiences and the social settings that comprise people’s
lives (Bryman & Bell, 2003); thus, it was particularly
relevant for exploring the real-life encounters of paramedics
leading on the front lines of patient care.

Participants were recruited using a purposive sampling
technique whereby all paramedics in this EMS group of
companies were invited via e-mail to nominate a paramedic
peer whom they believed exemplified outstanding leader-
ship at the front lines of care (e.g., in the field). Although
several more men than women were interviewed, the
percentage of women in the sample is representative of the
paramedic field in general (e.g., 75.7% male and 24.3%
female; Service Canada, 2011). The participants’ level of
experience in paramedicine ranged from 3 to 30 years,
suggesting a wide range of leadership experience. Partici-
pants’ formal training and certification included primary
care paramedic (PCP), advanced care paramedic, and in-
tensive care paramedic. Selection of interview participants
was made based on factors such as the reason given for the
nomination, geographic diversity, gender, years experience,
and certification (to ensure diversity). Having such a di-
verse sample of participants improved our chances of captur-
ing the most fruitful data. The demographic details of our
participants are found in Table 1.

Twenty-nine paramedics were interviewed for this study.
Because of the geographic dispersion of our participants, it
was not possible to conduct interviews face-to-face; thus,
telephone interviews were conducted. The interviews were
loosely structured and open ended and designed to en-
courage personal relevance and context (Holloway &
Wheeler, 2002). Our goal was to focus on the participants’
rich experiences in relation to, and within the context of,
leading on the front lines of care.

The interviews were semistructured in the sense that
some questions were developed before collecting data, but
we altered these questions and provided different questions
depending on the direction of the interview (Fontana &
Frey, 2005). All interviews were initially guided by the
statement: BWe are interested in examining the kinds of
leadership that happens on the front lines, not organiza-
tional or formal leadership positions but the kind of
leadership that paramedics do all of the time as part of their
everyday work.[ Interview prompts included BI am trying
to understand what leadership looks like for paramedics at
the front line of care, can you describe leadership from your
perspective?[, BCan you think of a time when you saw or
experienced effective or exceptional leadership?[, and
BCan you describe the qualities or characteristics needed for
leading in EMS?[.

The length of the interviews ranged from approximately
20 minutes to 1 hour. We taped recorded and transcribed
all of the interviews, which resulted in approximately
250 pages of interview text. We conducted interviews
until we felt that sufficient data were collected and reached
theoretical saturation (Glaser & Strauss, 1967) in the sense
that no new data were emerging in our interview responses.

Data Analysis

In analyzing the interview data, we followed Miles, Huberman,
and Saldana (2014) by iterating between data collection,
data analysis, and theory conceptualization. During the
interview and transcription process, we took notes on
potential themes that could be explored in future in-
terviews as well as generating the initial series of codes to be
used for the open coding stage of our study. During this
process, the authors spoke several times a week to discuss
the interpretation of the data, the codes and themes, and
the relationship of the findings to the current literature.

For the interpretation of the transcripts, we used a hybrid
approach called Bblended grounded theory[ (Locke, 2001).
Grounded theory (Glaser & Strauss, 1967) is aimed at
developing a new theory, which is grounded in the data,
rather than testing existing theories and uses an inductive
(e.g., bottomYup) investigation of the interview data.
Blended grounded theory, on the other hand, is used when
the research is meant to Bbring a new perspective and new
theorizing to an established theoretical area[ (Locke, 2001,
p. 97). Although paramedic leadership is a new area of
exploration, there is a history of research related to shared
leadership models in general. Therefore, we wanted to
utilize this literature and theory as our starting point.

For the actual coding, we followed Strauss and Corbin’s
(1990) guidelines for grounded theory research. First, the
authors read the transcripts related to the topic of informal/
shared leadership making notations and open codes related
to the conceptualization of paramedic leadership specifi-
cally. In this step, we broke down the data, compared

Table 1

Demographic information for the study
respondents

n %

Gender
Female 6 21
Male 23 79

Years of experience Mean = 13
Paramedic certification
Primary care 19 66
Advanced care 7 24
Intensive care 3 10

Geographic location
Province 1 2 7
Province 2 12 41
Province 3 15 52

Leading on the edge 15

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

similarities and differences, and grouped responses in specific
initial codes to be identified for further analysis. Through-
out this process, new open codes were developed, and certain
codes were dropped or combined under different codes.
Some of the following were utilized as initial codes of para-
medic leadership: knowledge, experience, accountability,
prioritizing, coaching, calm demeanor, counseling, collab-
orating, leading without hierarchy, trust, communicator,
and so forth. We hired a research assistant to develop tables
and taxonomies with instances of each of the initial codes.
The research assistant was provided with a definition of each
open code (i.e., calm demeanor was described as controlling
emotions so that it appears that you are confident and in
control regardless of how you feel on the inside) and was
asked to read the transcripts, code all relevant examples in
the responses, and then create a table for each code. Once
initial open coding was completed, which occurred when
all responses relevant to informal and shared leadership
were captured by at least one code, we grouped these codes
into higher-order codes. This was composed of axial and
selective coding as outlined by Strauss and Corbin. For
example, our Bknowledge,[ Bexperience,[ and Baccount-
ability[ codes were grouped together as Bcompetence.[ Our
Bcollaborating,[ Bleading without hierarchy,[ Btrust,[ and
Bcommunicator[ codes were combined to form Bcollab-
oration.[ Upon completion of transcribing, the higher-
order codes consisted of four main themes (i.e., leadership
as a collective sense of responsibility, shifting leadership
roles based on urgency and competency, informal leader-
ship in the absence of formal management, and informal
leadership practices promoted by formal management)
related to the precursors, practice, and structure of informal/
shared leadership.

Findings

Four distinct themes emerged from the data concerning the
ability of paramedics to engage in leadership on the front
lines of care. A summary of these themes is presented

in Table 2. In examining the themes, they seem to represent
the precursors of shared leadership, the practices of shared
leadership, and the structural conditions allowing shared
leadership to emerge. We will discuss each theme in greater
detail below.

Precursors of Shared Leadership

Theme 1: Leadership as a collective sense of
responsibility. Given previous arguments in the literature,
one might assume that traditional (i.e., hierarchical)
leadership models work better in times of crisis (Pearce &
Manz, 2005), but several of the respondents highlighted
the importance of leadership as being a shared responsibility
between all team members. As exemplified below, leadership
is a collective team-based norm between paramedics used to
maximize patient outcomes.

R25: What’s different about EMS in our field, we
don’t have captains, we don’t have lieutenants, we
don’t have chiefs, we are all just individuals that, I
guess we just assume the role [of leadership].

R14: You definitely need a working relationshipIwe
always discuss things prior to getting on scene, we’ll
try to picture the crash as we’re seeing in our heads as
we’re seeing our computerIwe’re trying to play it out
prior to getting thereIwe’re a team.

Similarly, the respondents shared the belief that
leadership relates to synergy. For example, Respondent
20 stated, Bwell leadership is first of all looking after each
other, it’s taking care of yourself and your partnerI.[
The following respondents further support the idea that
leadership is a mutual partnership based on professional
development:

R12: II’m working with a newer person or if
they’re not quite that confident. I like to let them

Table 2

Paramedic leadership themes

Theme Theme summary

Leadership as a collective sense of
responsibility

Defined as the importance of leadership being viewed as a shared responsibility
between all team members. Leadership based on synergy.

Shifting leadership roles based on
urgency and competency

The sense of urgency and immediacy paramedics face in emergency situations
when deciding to delegate an active leadership role. This leadership role is
based on tangible and observable skills/competency required to treat the patient.

Informal leadership in the absence
of a formal leader

The natural tendency to step up and emerge as leader(s) when a formal
supervisor was unable to be present in the decision-making task.

Informal leadership practice
promoted by formal leaders

Support and encouragement from formal supervisors in using a variety of
unconventional leadership practices by paramedics.

16 Health Care Management Review JanuaryYMarch & 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

kind of take the lead, but they’re taking the lead
knowing I’m right there to back them upI.

Theme 2: Shifting leadership roles based on urgency
andcompetency.Anothernoteworthyprecursorinfluencing
the paramedics’perceptionand practice of shared leadership
was the sense of urgency they faced in emergency situations
to ensure patient-centered care. For example, one respondent
discussed the importance of being able to rapidly delegate
an active leadership role in times of trauma:

R4: Ultimately the finest leadership is during
heightened emergencies, like mass casualties, I’ve
been to car accidentsIand I’ve seen effective leaders
who can control the scene, and effect a plan and
orchestrates the plan for everybodyI.

As shown in the exemplars below, the respondents
also coordinate and transfer the leadership role between
(inter) professionals when patient health and/or safety
are at stake. This leadership status was contingent on the
task at hand.

R23: All of a sudden we heard a callItree on top of a
car, two patients trappedI. We had to determine
which patient was best to get out of the car firstIbefore
we got the more serious outIso we kind of had to
coordinate and show some leadership in that sense as
to direct the fire department on which patient we
want out first.

The respondents described the nature of one’s skill base
as a precursor to whether a paramedic would share and/or
transfer the leadership role in situations requiring immedi-
acy. These skills are tangible and observable and relate to
the practice of paramedicine and ensuring the best standard
of patient care:

R13: We both had a couple of things that personally
didn’t go well for us on that call, but we were able to
pick up the slack for each otherIlike I couldn’t get
the IV and she couldn’t get the endo-tracheal tube, so
she got the IV and I got the endo-tracheal tube.

As well, there seemed to be a unanimous understanding
between all paramedics that leadership was supposed to
shift. Leadership is not viewed as a rotating disposition but
rather as a position that any paramedic unit could enact.
For some, this was a natural and unspoken exchange based
on competence as described below:

R11: Iwhen somebody isn’t capable of doing the
call, it’s almost like there isn’t any conversation, the
other person just steps up and does itI. We don’t talk
about who’s in charge, it just happens.

Shared Leadership Practices

Theme 3: Informal leadership practices in the
absence of formal management. In the absence of a
formal supervisor, paramedics have a natural tendency to
step up, take charge, and effectively engage in leadership.
The mentality that someone should informally assume a
heroic or shared leadership role in a chaotic situation was
voiced by many respondents:

R11: There are times when we have had mass casualty
things, and when a supervisor shows up on scene,
they are expected to lead, but when there is no
supervisor on scene, there is a natural selection, for
lack or a better term, that happens, when a leader will
emerge, in the dynamic call, and lead the call.

Other respondents highlighted the value in viewing
leadership as a relational process. The paramedics consid-
ered any individual who had the ability to influence,
motivate, communicate, and lead by example to be defined
as Bleaders[ in their eyes:

R1: They didn’t wear any stripes, or have any rank to
be a leader, but just how they interacted, diffusing
situationsI. I think that’s a tremendous skill for
anyone to have.

R4: He shows, he can paint a vision, and you are often
motivated to become a part of that vision, and if you
act on it, he will empower you to do something,
although it may not be in the realm of his authority,
but within the area of his competence.

Most notable in this theme is that the respondents un-
derstand that leadership extends beyond Bfigureheads at the
top[ (Fletcher, 2004). Furthermore, the paramedics felt
that, to successfully achieve patient care, one must rise to
the occasion in the absence of a supervisor and engage in
specific behaviors enacting an informal but influential
leadership role.

Structural Conditions Surrounding Shared
Leadership

Theme 4: Informal leadership practices promoted
by formal managers. Respondents reported that their
formal paramedic supervisors supported and encouraged
the use of informal leadership practices. In the exemplar
below, the respondents described the importance of trust,
confidence, and support:

R2: No he’s kind of letting us spread our wings and fly,
but always, always in the background, whenever we
need him, like personally, medically, anything.

Leading on the edge 17

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Because a few of the respondents in the study were
formally ranked as supervisory paramedics, they too spoke
of the crucial role in engaging in less structured leadership
behaviors to allow for informal and shared leadership to
emerge among fellow paramedics. This not only gives
paramedics the freedom to act independently but also
promotes the idea of leading by example.

R12: I found that with my leadership style, you have
to be able to make yourself step back a little bit, let
that person kind of develop themselves, let them
push their boundaries a little.

R26: So one of the best things for us is to lead by
exampleI. If you have somebody who can step up
and take charge, maybe the person behind you will do
the same thing.

Although much leadership research has been concen-
trated on individuals in formal positions of authority, pa-
ramedics in this study clearly illustrated the conditions
enabling informal/shared leadership models to thrive. The
respondents show that not only do front line paramedics
enact leadership but supervisors’ behaviors also play a role
in encouraging these practices.

Discussion

In this study, we explored the antecedents and conditions
surrounding shared leadership practices among paramedics
leading on the front lines of patient care. Although we
cannot extend our findings to the general population of
health care professionals, we argue that our article con-
tributes to the virtually nonexistent literature on informal
and shared leadership of paramedics. We hope that our
findings will inspire other researchers to question tradi-
tional assumptions about hierarchical models of leadership
at the front lines of care.

Paramedics argue that, by engaging in informal leader-
ship practices, they can capitalize on individual strengths in
different situations to maximize successful patient out-
comes. Klein, Ziegert, Knight, and Xiao (2006) conducted
a grounded theory semistructured interview study with ex-
treme action teams in an emergency room and found that
respondents reported the existence and importance of using
a hierarchical, de-individualized system of shared leader-
ship. The hierarchical leadership piece related to an under-
standing of who to defer to in moments of uncertainty. In
the current study, paramedics continually emphasized the
importance placed on competence, judgment, and intui-
tion when determining whether to enact a leadership role
or to take a step back. As paramedics received higher cer-
tification levels, their scope of practices increased, and this
may have been a factor in who stepped up and took the
leadership role in a given situation. In Canada specifically,

there are three different levels of certificationVprimary
care paramedic, advanced care paramedic, and intensive
care paramedic. As the level advances, the paramedics are
given a broader scope of practice as it relates to medication
administration, defibrillation, advanced airway management,
and other invasive treatments. However, our interview re-
spondents did not specify formal paramedic certification
levels as the primary means of determining a leadership
role. Urgency of patient care on the other hand influenced
the shifting of leadership between paramedics. The para-
medics had a mutual understanding that, in times of urgency,
whoever had the highest competency in a given skills would
assume the position of a leader.

The findings in this study also show the importance of
paramedic supervisors in promoting and encouraging
models of informal and shared leadership. Yes, traditionally,
paramedics follow the leadership of supervisors, but when
no supervisor is present on the front linesVwho leads in
such a situation? If no supervisor is present, who tells the
paramedics what to do? These questions extend beyond the
paramedic literature because organizations in many indus-
tries are becoming more decentralized and team based and
there is the realization that a single individual cannot
possess all of the traits and skills necessary to make every
decision. As shown in this study, informal leadership is one
way to help cope with organizational complexity. Informal
leadership encourages anyone to influence the behaviors of
others to achieve a particular goal. However, for informal
leadership practices to be successful, formal management
must be supportive. The respondents argued that their man-
agers sought to engage the leadership capabilities of all levels
of paramedicine. VanVactor (2012) noted that, in an effort
to promote leadership outside traditional bounds, health care
managers should take a proactive step in recognizing that all
team members have the ability to be leaders dependent on
the context. Implicit in this perspective is not a disregard for
formal management positions but recognition of the impor-
tance of supporting and encouraging leadership distributed
throughout the organization (Fletcher, 2004). The current
study shows that formal and informal leadership are two
interdependent entities supported by managers and para-
medics. The paramedics voiced the belief that any paramedic
could emerge as a leader, and managers recognized and ap-
preciated this perception. A topYdown hierarchical leader-
ship model is often viewed as the most effective in crisis
situations (Pearce & Manz, 2005), but the respondents here
explain the difficulty in a manger being present in every
situation and thus question the effectiveness of focusing on
singular leadership models (Weberg, 2012). Perhaps, most
noteworthy is the consideration and promotion by managers
of informal and shared leadership practices. These data
suggest that managers in complex and dynamic health care
environments can capitalize on the leadership strengths of all
organizational members to most effectively reach decisions
and meet demands. We argue that many health care fields

18 Health Care Management Review JanuaryYMarch & 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

can learn from this as a model in taking a more proactive
stance on the promotion and distribution of leadership
capacity throughout their organizations.

Limitations

This study also has limitations. The primary focus of this
study explored paramedics and their perceptions of leader-
ship; therefore, we cannot assume that the informal/shared
leadership models and management support will shift to
other health care professionals. Our study was meant to
capture how informal leadership practices are beneficial
and could be encouraged by management across situations.
Although the paramedics argued that they are Bleaders[
and that their supervisors encourage them to enact leader-
ship, we did not interview formal supervisors to gather their
input on the implementation of informal leadership prac-
tices. Future research might consider an in-depth case study
with both paramedics and their managers to strengthen
credibility.

Practice Implications

The findings outlined in this study indicate that, although
informally practiced, paramedics perceive leadership to be a
necessary competency for clinical practice. According to
the National Occupational Competency Profile of the
Paramedic Association of Canada, there are eight compe-
tency areas required for all levels of paramedics. These
include professional responsibilities, communication, health
and safety, assessment and diagnostics, therapeutics, inte-
gration, transportation, and health promotion and public
safety. Currently, leadership is not recognized as a major
area of competency. However, the lack of attention paid to
leadership development among paramedics extends beyond
Canada and is a global issue (O’Meara et al., 2010). In
2007, the EMS chiefs of Canada released a report entitled,
BThe Future of EMS in Canada: Defining the Road Ahead.[
In this report, they discuss six key strategic directions
including leadership support. They discuss the lack of
formalized leadership programs for managers in EMS. We
argue that leadership development should extend beyond
managers and include all levels of paramedics. In practice,
paramedic associations and organizations might consider
developing and implementing leadership modules as part of
their core curriculum and training upon entrance to the
paramedic program (i.e., in Canada, the first certification is
the PCP Program). Canadian paramedic schools currently
offer elective short training courses and may benefit from
offering a targeted leadership certificate course that de-
velops the knowledge and skills in paramedic leadership.

Specific to those health care organizations that employ
paramedics, managers can also promote an environment of
shared leadership and encourage paramedics to practice
leadership with quality of patient services in mind. Informal

leadership practices can be constrained by barriers such as
boundary conditions and formal hierarchical control. As
we have shown, supportive management that promotes
internal shared leadership between paramedics allows them
to maximize their scope of clinical practice in times of
uncertainty and during urgent calls. Health care organiza-
tions specifically can benefit from having a culture of shared
leadership to bolster patient outcomes and satisfaction. At
the formal policy level, organizations can provide education
and training to all levels of employees as a foundation for
the practice of informal and shared leadership throughout
their organizations.

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48 Healthcare Quarterly Vol.20 No.2 2017

Abstract
The Economic Value of Community� Paramedicine Programs
Study� was a randomized controlled trial in two Eastern
Ontario communities – one urban and one rural – to deter-
mine whether community� paramedicine services (the
intervention through home visits) would have a positive
economic impact through influencing self-perceived quality�
of life and determining a monetized value. A total of 200
clients who were high-users of healthcare services and
had one or more of five chronic diseases (congestive heart
failure, chronic obstructive pulmonary� disease, hy�perten-
sion, stroke and diabetes) were recruited in early� 2015. These
participants were randomly� assigned to either the interven-
tion group (receiving community� paramedicine services for
12 months) or the control group (receiving conventional
treatment). Study� results suggest that although quality� of
life scores decreased for all groups, those receiving commu-
nity� paramedicine services demonstrated significantly� less
reduction in their scores. Suggestions to further increase
cost efficiency� of this novel service are given.

Introduction
The concept is proving effective. The practice of community
paramedicine (CP) has arisen from grass roots innovation to
meet community needs by local paramedic services leveraging
their skills and knowledge to address non-emergent client

presentations. In contrast to the traditional stabilize and trans-
port clients to emergency rooms for assessment and manage-
ment, medics are additionally focussing on preventative measures
to support clients to live in their home as long as possible.

As O’Meara et al. (2016) notes, CP has appeared as a
solution to many of the healthcare system’s vexing issues as
a result of increasingly higher education for paramedics and
growing acceptance by other providers and clients that this
profession has much to offer beyond its traditional role charac-
terized by expediency. Paramedics have evolved from being
ambulance attendants to part of the primary healthcare team
through increasingly robust entry-level education programs as
well as continuing didactic and clinical training programs. This
expanded skill and knowledge set has enabled paramedics to
evolve beyond conventional practice and more fully collaborate
with physicians, nurses and other allied health professionals.

The major issues community paramedics are addressing
are complex, while well elaborated in the healthcare literature
(Health Quality Ontario 2012). These include:

• With 5% of the Canadian population consuming 50–67%
of resources, the need has evolved to change the health and
wellness profile of this group of citizens.

• In addition to increasingly scarce resources, the healthcare
system remains fragmented and the literature additionally

Conserving Quality of Life through
Community Paramedics
Christopher Ashton, Denise Duffie and Jeffrey Millar

CARE IN THE COMMUNITY

Healthcare Quarterly Vol.20 No.2 2017 49

points to the need to not only streamline processes
within healthcare as well as integrating with social service
supports to address underlying determinants.

• With one in five people with congestive heart failure and
chronic obstructive lung disease presenting with readmis-
sion to hospital within 30 days of discharge, the rate of
progress in supporting the transition from hospital to
home needs to be accelerated.

In the context of Canada’s well-developed public health-
care system, these issues are vexatious; it follows that innova-
tive approaches are needed and be geared to promoting the
wellness of people in their homes. Chronic disease is largely
mediated by social determinants of health (SDHs) (PHAC
2011). Social determinants are those factors affecting people’s
health as a result of societal, community and family pressures
that positively or negatively affect health. CP, in addition to
providing primary assessment, treatment, prevention and
management, as well as a healthcare navigation function to
address health and social conditions, operates in the realm of
SDHs by meeting people where they are, at home.

This window into people’s lives allows CPs a view beyond
what is seen in clinics and offers much insight into how daily
living can be better supported and potentially raise the health
profile of those dealing with chronic disease and multimor-
bidities. Although numerous models of CP have been reported
(Bigham et al. 2013), the commonality of these models has been
their tailored response to local needs. In some cases, they are
well defined and protocol driven such as extended paramedic
practitioners in the UK (Mason et al. 2007, Dixon et al. 2009)
and in others they are fluid and operate in multiple locales in
response to specific needs and care gaps such as the CP programs
in Renfrew County, Ontario (O’Meara et al. 2016).

Viewing this service as one that increases community resil-
ience, the Canadian Safety and Security Program sponsored a
two-year, multiple-location randomized controlled trial (RCT)
to assess the economic impact of CP. One year was allotted
for the field phase with the remainder for planning, education
and analysis. Of the various models for CP, that of regular
home visitation supplemented by response to CP requests for
in-home service as undertaken in Renfrew’s Aging at Home
program was chosen as best poised to address the needs of
high healthcare system utilizers (Canadian Safety and Security
Program 2014; O’Meara et al. 2016). This study was also in
response to literature calls for further evidence regarding this
practice, as well as exploring its potential in urban as well as
rural environments.

The Aging at Home program has evolved to be effective
and sustainable in Renfrew over the past decade. Working
in close collaboration with other local healthcare and social
service agencies, paramedics service clients broadly within

their existing scope of practice under the Ontario Provincial
paramedic medical oversight model. With primary or advanced
paramedic training supplemented by additional training, CPs
in this program now have a proven safe (Mason et al 2007)
skill set suited to managing chronic disease. A list of skills and
competencies is provided in Box 1.

Methods
In addition to the rural setting in Renfrew, this study included
new CP service provision and participation in the urban areas
of Hastings County, Ontario. Paramedics from the Quinte
Emergency Medical Services detachment in Belleville received
the same supplemental training and were coached by the
Renfrew CP prior to commencing home-based practice.

A total of 200 eligible clients (120 for Hastings and 80 for
Renfrew) were recruited in early 2015 and randomly assigned
to either the inter vention group (receiving communit y

Christopher Ashton et al. Conserving Quality� of Life through Community� Paramedics

BOX 1.
Key skills for community paramedics

• Level of responsiveness
• Fall risk assessment
• Level of awareness
• Fall risk prevention
• Glasgow Coma Scale
• Safe home mobility assessment
• Pupillary response
• Post fall assessment
• Skin condition
• Get up and go assessment
• Temperature
• Mini mental health assessment (Dementia)
• Heart rate, rhythm, quality
• Mental health status assessment (Coping)
• Electrocardiography (ECG) interpretation
• Urinary catheterization
• 12-Lead interpretation
• Urine dip test
• Lung sounds
• Advanced wound care
• Respiratory rate, regularity, quality
• Antibiotic therapy
• Blood glucometry
• Foot assessment and foot care
• Venipuncture (draw and catheterize)
• Influenza vaccinations
• History assessment
• Dealing with death and dying (patient attachment)
• Medication compliance
• Patient interview (building and maintaining rapport)
• Health literacy and education
• i-STAT blood analysis
• Intramuscular injections
• Mental health crisis intervention
• Emergency advanced life support (ALS) care
• Subcutaneous injections

50 Healthcare Quarterly Vol.20 No.2 2017

paramedicine services) or the control group (receiving conven-
tional treatment). All of these clients had used a Paramedic
Service ambulance to go to a hospital emergency room (ER)
three times or more in the preceding year, and had one or
more of the following chronic conditions: chronic obstruc-
tive pulmonary disorder, congestive heart failure, diabetes,
hypertension or stroke.

Clinica l acumen on the part of the project Steering
Committee, as well as the literature, recognized the progres-
sivit y of these chronic diseases and that CPs would be
working with a challenging study group. Agborsangya et
al. (2012) speak to the highly positive association between
chronic disease and especially multimorbidity with ER and
hospital utilization. In their cross-sectional questionnaire
survey conducted in Alberta, multimorbidity was associated
with a clinically important reduction in self-reported quality
of life scores and twice the likelihood of being hospitalized
or having an ED visit.

Given t h is prog re ssiv it y of d isea se a nd u su a l c a re
pathways already entrenched in our study group, our notion
was that over the course of 12 months, CP would be consid-
ered successful should it show a decrease in the trajectory
of disease progression in the intervention compared to the
control group. To explore this, a three-year retrospective
analysis was undertaken to plot all participants’ utiliza-
tion of paramedic, ER and hospital admissions. Among the
intervention and control groups through the f ield phase, a
comparative interruption in this utilization trajectory was
postulated to inform the success of the trial. This inter-
rupted trajectory is well demonstrated by the Renfrew group
in Figure 1.

Due consideration was given to basic concepts and measure-
ment tools for best determining the possible economic value
generated by CP in this study. Within the past decade of
Canadian healthcare, it has become popular to consider
healthcare service as a value-laden proposition and measure
its effectiveness in that context. The previous view taken upon
healthcare as mainly a cost to societies to be minimized while

maintaining quality through increased efficiencies has given
rise to:

“often conflicting goals, including access to services,
profitability, high quality, cost containment, safety,
convenience, patient-centeredness, and satisfac-
tion. Lack of clarity about goals has led to divergent
approaches, gaming of the system, and slow progress in
performance improvement (Porter 2010).”

Value, a product of measuring outcomes relative to costs,
encompasses efficiency. Therefore, any healthcare trial which
seeks to determine value of an intervention will inherently
incorporate the inf luence of efficiency; the question remains as
to how to define value in healthcare from this perspective. Cost
of this intervention, community paramedicine services, were
readily derived through determining the cost of the CP service.

Value in this project was measured for those patient groups
with predominantly one of five chronic diseases, that is, conges-
tive heart failure, chronic obstructive pulmonary disease,
hypertension, stroke and diabetes for the summary aggre-
gate. Client participants in this study were all high-intensity
users of 911, ERs and hospital admissions. Porter (2010) states
“Providers tend to measure only what they directly control in
a particular intervention and what is easily measured, rather
than what matters for outcomes.” He further purports “For any
condition or population, multiple outcomes collectively define
success. The complexity of medicine means that competing
outcomes (e.g., near-term safety versus long-term functionality)
must often be weighed against each other.”

For this project, we have defined value through the use of
quality-adjusted life year (QALY). The term quality of life is
highly subjective and varies considerably across nations and
cultures; any instrument used to measure this must take into
account local preferences for health (e.g., heart disease consid-
ered worse to have than arthritis in the UK) as well as be
valid and reliable across various disease states. For all reasons
discussed to this point, the measurement instrument chosen
was the EuroQol Group’s EQ 5D 3L. As there to date has not
been a Canada-wide valuation of preference indices chosen,
we chose the United States indices as our closest comparison.

The 2012 Symposium Proceedings for Patient-Reported
Outcomes Measurement in Alberta (IHE 2012): Potential of
the EQ-5D introduces the instrument as:

“The EQ-5D (‘EuroQol – five dimensions, three
levels’) is a patient-reported outcomes measure that
captures five dimensions of health-related quality of
life: mobility, self-care, usual activities, pain/discomfort,
and anxiety/depression. It is appealing as a standard-
ized health outcomes measure for Alberta because, as

Conserving Quality� of Life through Community� Paramedics Christopher Ashton et al.

FIGURE 1.
Paramedic service transports to hospital

P
er

ce
nt

ag
e

0

20

40

60

80

100

Period (February 1 to January 31)
2012–2013 2013–2014 2014–2015 2015–2016

Renfrew intervention Renfrew control

Healthcare Quarterly Vol.20 No.2 2017 51

a generic measure, it is applicable to a wide range of
health conditions and can be used as a research tool at
both the population health and program levels, and has
potential as a clinical monitoring tool. It is designed
for completion by the patient, is quick and easy to use
and adaptable for use in surveys, face-to-face interviews
or the clinical setting. It is commonly used around the
world in clinical, population health, health economics
and research applications.”

Speaking to the current context of healthcare and research
we are in, the Symposium acknowledges a strong rationale for
obtaining patient-reported outcome measures:

“the goal of a patient-centered healthcare system is
to improve the health and functioning of patients …
Moreover, self-care is an important part of healthcare,
so obtaining some level of measurement of patient
health and health behaviors will be important for the
overall evaluation of health and healthcare.”

CP, as a primary care provider, acts at the interface of
the patients and numerous other elements of the primary
care system working toward seamless delivery of healthcare.
It has been postulated that community paramedics (CPs)
can stimulate use of underutilized, relatively inexpensive
communit y-based ser vices (Mason 2008). Because CPs
generally have a broad knowledge of health conditions and
associated service providers, it is also thought that client
utilization of community services becomes more integrated
and efficient.

Results
The initial 200-person sample was recruited according to the
designated inclusion criteria with Hastings-Quinte Paramedic
Service recruiting 120 (60 each in intervention and control
groups) and Renfrew County Paramedic Service recruiting 80
(40 each in intervention and control groups). The Hastings-
Quinte region was the designated urban area so all recruiting
was executed in the cities of Belleville and Trenton in Quinte
West. Renfrew County was the designated rural area and all
recruiting was executed across the entire county.

Table 1 summarizes the challenges of recruiting sufficient
participants from a target population characterized by chronic
illness – the numbers of potential participants deceased signifi-
cantly by the time the study began or could not be reached
to determine their participation interest. This latter challenge
was particularly acute in Hastings-Quinte, whereas Renfrew
County also experienced recruitment challenges from potential
participants moving to long-term care (LTC) or outside the
study area.

As demonstrated in Table 2, both communities suffered
significant losses in their sample groups during the field phase
period (from February 1, 2015 to January 31, 2016). For instance,
each community lost at least 10% of the starting sample to death
and Hastings-Quinte lost 9.5% of their sample to transfer to
LTC. Renfrew County experienced significant sample losses to
withdrawals (13.7%), reasons for which are unknown, and was
unable to reach 18.7% of the sample (mostly in the control group)
because of the inability to reach them at the study’s conclusion.
Data loss in this regard was mitigated by the researchers’ ability
to determine whether death was the reason for study exit.

Paramedic service transports for clients to ER were gathered
for three years prior to study commencement and followed
through the field phase. Results implied that there was signifi-
cant escalation of the specific target population’s healthcare
service needs over the course of three retrospective years. This
pattern is quite pronounced in both communities and suggests

Christopher Ashton et al. Conserving Quality� of Life through Community� Paramedics

TABLE 1.
Summary of sample recruitment from a master list of
eligible participants

Sample disposition category Hastings-Quinte Renfrew Total

Total number of eligible clients
(met criteria)

485 233 718

Deceased (at time of
recruitment)

18 26 44

Moved to long-term care or
outside study area

2 55 57

Declined to participate 5 30 35

Unable to contact 340 42 382

Recruited into study 120 80 200

TABLE 2.
Disposition of sample for Hastings-Quinte and Renfrew
county study groups

Status

Renfrew Hastings–Quinte

Total Control Int. Total Control Int.

Deceased 9 5 4 18 10 8

Moved 7 3 4 3 2 1

Hospitalized 2 0 2 5 1 4

Nursing home 0 0 0 12 5 7

Not reached 15 12 3 0 0 0

Withdrew 11 0 11 1 0 1

Discharged 1 0 1 0 0 0

Complete 35 20 15 87 42 45

Totals 80 40 40 126 60 66

Int. = intervention.

AU: Table details and text numbers do not match (some highlighted; e.g. Hastings–

Quinte total = 120 or 126?). Please double-check all the numbers in tables & the

various mentions in the text and confirm any changes that need to be made

52 Healthcare Quarterly Vol.20 No.2 2017

that significant chronic disease progression was taking place
in the period leading up to the study’s field phase.

Cost-utility analysis was performed through comparing
entry and exit study EuroQols among the control and inter-
vention group, individually and for the aggregate. We used the
EuroQol 5D 3L, usage of which was granted by the EuroQol
Group. As mentioned previously, there are f ive domains
(mobility, self-care, usual activities, pain/discomfort and
anxiety/depression) which are scored one, two or three. EQ
5D 3L indices range from 1 through zero to −0.6. One (1) is
perfect health, diminishing to zero (0) which is death, and
indices below zero represent states worse than death.

Aggregate scoring demonstrating the change in EQs
is shown in Table 3.

As shown, the average self-reported quality of life scores
decreased for all groups, intervention and control, through the
12-month field phase. Given our notion that our study popula-
tion was dealing with progressive, chronic disease(s), these
results are not surprising. Nonetheless, it is significant to note
that the rate of decrease in EQ 5Ds is less for both intervention
groups (0.084 for Renfrew and 0.075 for Hastings) compared
to the controls. This would imply that regardless of other
outcomes, the community paramedicine intervention conserved
quality of life compared to groups receiving usual care.

Economic impact of CP through conserving quality of life
was monetized through conversion to QALYs and considera-
tion of the cost of the intervention. Per client marginal costs
for one year’s CP service through this study was calculated to
be $5,675 for Renfrew and $5,731 for Hastings. On that basis,
cost to realize a QALY through this community paramedicine
intervention was $67,560 for Renfrew and $76,413 for Hastings.

Discussion
The National Institute for Health and Care Excellence (NICE,
or the Institute) provides guidance to the National Health
Service in England on the clinical and cost effectiveness of
selected new and established technologies. According to NICE,
the expression for health effects should be in QALYs. The EQ
5D is their preferred measure for health-related quality of life
in adults.

On admission to the study, participant EQ 5D scores
averaged 0.56 This mean score is less than 0.79 which has been
proposed as being consistent with a much higher use of health-
care resources (Agborsangaya et al. 2014). Given the extent
of chronic disease, multimorbidities and age of our partici-
pants, decreased quality of life because of disease progression
as expressed through EuroQols was anticipated.

While it may seem that the change in EQ 5D scores was
small for both study locations, the lessened rate of increase
for the intervention groups of 0.084 and 0.075 can be consid-
ered clinically significant. It has been reported that any change
in EQ 5D scores greater than 0.03 should be considered as
significant (Agborsangaya et al. 2014).

Economic impact as expressed through cost per QALYs are
higher than those which NICE would consider an attractive inter-
vention. NICE guidelines suggest that a new technology costs less
than £20,000–£30,000. This study showed a significantly higher
cost than the NICE guidelines. We also reaffirm our notion that
a gain of QALYs would be highly challenging in this sample of
participants with advanced and progressive chronic disease.

Calculations were dependent on a predetermined number
of participants recruited to the study. Given the research roles
assigned to the paramedics and learning curve of a new service
now managing clients with significant morbidities, we believe that
CPs could follow a larger clientele which would reduce the cost
per QALY significantly. Leveraging technology through providing
clients with remote patient monitoring followed by CPs has also
been suggested to decrease costs to an attractive rate by increasing
the number of clients that individual CPs could follow.

Conclusions
This article reports on one of the few RCTs undertaken
regarding CP. Among its unique features, the participant group
presented a great challenge for the caregivers in attempting to
conserve quality of life and reduce utilization of acute care
facilities as well as LTC institutions. Where other studies have
concentrated on the use of medics in the home to address acute
issues and attempt to provide local care rather than transport to
ERs, our study focussed on regular visitation and monitoring
to alleviate the trajectory of chronic disease.

While it would have been a major success to have demon-
strated a more attractive cost per QALY through this study
and analysis, nonetheless it was shown that this type of CP did
significantly conserve quality of life. Through assigning a greater
clientele rather than a fixed number to community paramedics
as was done in this study, it is most likely that costs of the service
to achieve benefits in quality of life would decrease.

Additionally, leveraging technology through remote patient
monitoring has been shown to allow paramedics to care for
more patients in their home. Further work in this regard would
illuminate the possibilities.

TABLE 3.
EuroQol changes for Renfrew and Hastings

County Group

Change in EuroQols

ValSet Average Total %

Renfrew Intervention −1.673 −0.076 −13.42

Renfrew Control −4.148 −0.160 −33.62

Hastings-Quinte Intervention −0.948 −0.020 −3.87

Hastings-Quinte Control −4.738 −0.095 −15.67

Conserving Quality� of Life through Community� Paramedics Christopher Ashton et al.

Healthcare Quarterly Vol.20 No.2 2017 53

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About the Authors
Christopher Ashton is executive vice president of HarbourFront
Health Group Inc., a research-intensive healthcare consulting firm.

Denise Duffie is president of HarbourFront Health Group Inc.,
a research-intensive healthcare consulting firm.

Jeffrey� Millar is a paramedic with the Renfrew Paramedic
Service and is A/Commander Community Paramedicine.

Christopher Ashton et al. Conserving Quality� of Life through Community� Paramedics

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http://www.ihe.ca/publications/patient-reported-outcomes-measurement-in-alberta-potential-of-the-eq-5d-ndash-symposium-proceedings

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The Impact of Leadership Effectiveness on the Quality of

Health Care Service at Universiti Sains Malaysia Hospital

(HUSM), Kubang Kerian, Kelantan, Malaysia

Dr. WAN AFEZAH WAN ABDUL RAHMAN
School of Distance Education Universiti Sains Malaysia

11800 USM, Penang, Malaysia

E-mail: afezah@usm.my

Tel: 604-653 5947

Fax: 604-657 6000

Abstract

This study aims to discover the impact of leadership effectiveness on the quality of health care service at

the university hospital in Kelantan, Malaysia. The study discussed the impact of leadership effectiveness in

providing a high quality, safe, efficient, and satisfaction to the patients. The research used two types of the

questionnaires: the Leadership Practices Inventory (LPI) survey developed by Jim Kouzes and Barry

Posner (2000) and the Consumer Assessment of Health Care Providers and Systems (CAHPS) which was

developed by the U.S Department of Health and Human Services (1995). The results showed that

leadership effectiveness correlated significantly with service quality. The study showed that the patients are

highly satisfied with the quality of health care service provided by Universiti Sains Malaysia’s Hospital.

Keywords: Leadership, Empathy, Quality, Management, Service.

Introduction

Leadership effectiveness is defined by a leader’s ability to mobilize and influence followers. Leadership

effectiveness depends mostly on the successful and punctual accomplishment of tasks from a leader’s set of

objectives. Leadership effectiveness is pivotal because it determines the success of organizations. This way,

organizations are able to improve their performance by increasing employee optimism, motivation, and

commitment, as well as organizational vision. Leadership effectiveness has been viewed as an important

part in promoting high quality health, reducing costs and improving patients’ satisfaction in health care

services.

The goal of health care services is to promote primary care, improve patient outcomes and improve public

health. Providing high quality and affordable health care services is an increasingly difficult challenge. This

is due to the complexities of health care services as well as systems, costs, quality, delivery, organization

and outcomes of health care services. Effective leadership is crucial for HUSM to maintain its quality

mailto:afezah@usm.my

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services for patients. This is because the issues of quality in the delivery of health services are critical in

assessing the effectiveness of quality health care and in evaluating health policies.

Background of the Study

There has been great concern regarding leadership effectiveness due to changes in market growth and rapid

globalization (Bailie, 2011). Thus, organizations aim to improve their performance in world markets by

strengthening leadership effectiveness (Noubar, Che Rose, Kumar, & Salleh, 2011; Ventakesh, 2006).

There is little information on understanding the differential impacts of leadership effectiveness on the

quality of health care service at HUSM. The research aims to examine the relationships between leadership

effectiveness and outcomes for the quality of health care service. It will investigate the impact of leadership

effectiveness and quality of health care involving the staff and patients at HUSM. The research will

interview about 353 staff and 361 patients.

Statement of the Problem

We always hear different stories and complaints from patients from different backgrounds from various

hospitals. There has been great concern regarding the quality of health care service at hospitals, especially

government hospitals (Raman, 2008). This is because hospitals have been trying to improve their services

in many ways. Everyday, hospitals and other health care providers face a lot of problems aside from dealing

with patients. These problems include efficiency, management, staffing, logistics, maintenance and others

(Becher & Chassin, 2001). This is because health care providers are facing strong competition due to the

industry’s movement towards managed health care systems. In order to create or sustain a competitive

advantage, health care providers are pressured to integrate with modern approaches, which stress leadership

effectiveness and quality of health service outcomes (Choi; Cho; Lee; Lee & Kim, 2002).

Leadership effectiveness plays a pivotal part in making sure that employees perform above and beyond

their abilities in providing the best health care services (Boseman, 2008). In this scenario, with effective

leadership, it can help to improve the quality of health care services at HUSM (Choi et al., 2002). Effective

leadership involves all groups, starting from the top leaders; the board directors to the lower management,

who work at HUSM. Effective leadership and outstanding employee performance is needed in order to set

up an excellent quality of health care service at HUSM so that it will be known for its excellent and

improved services. Thus, the study will explore the impact of leadership effectiveness, improving the

quality and outcomes of health care service.

Objectives of the Study

1. To determine the impact of leadership effectiveness on the quality of health care service at HUSM.
2. To find out if there is a need to increase the quality of health care service at Universiti Sains Malaysia

Hospital (HUSM), Kubang Kerian

3. To find out whether leadership effectiveness effects the employees’ satisfaction at

HUSM.

Purpose of the Study

The purpose of the research is to explore the impact of leadership effectiveness toward the total quality of

health care services at HUSM. Specifically, the research aims to increase the likelihood of achieving

desired health care outcomes as expressed by the patients as well as to protect and improve the health of

patients. The purpose of the research is also to improve the quality of health care services as well as clinical

practices and patient outcomes and also to reduce mistakes. The research will serve as an integral part of

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quality improvement programs in hospitals, clinics and health plans at HUSM as well as other hospitals.

Accordingly, the research will provide recommendations that may help leaders from HUSM establish the

importance of leadership effectiveness in health care services. Lastly, the study aims to give patients access

to the best possible health care services and resources in Malaysia.

Research Questions

1. Does leadership effectiveness impact the quality of health care service at HUSM?
2. Is there a need to increase the quality of health care service at Universiti Sains Malaysia Hospital

(HUSM), Kubang Kerian?

3. Does leadership effectiveness effect the employees’ satisfaction at HUSM?

Research Hypotheses

To answer the research questions, the following hypotheses will be tested:

H01: There is a significant relationship between leadership effectiveness and quality of health care service at

Universiti Sains Malaysia Hospital (HUSM), Kubang Kerian.

H02: There is a need to increase quality of health care service at Universiti Sains Malaysia Hospital

(HUSM), Kubang Kerian.

H03: Leadership effectiveness does effect the employees’ satisfaction at HUSM.

Significance of the Study

The significance of the research to the domain of leadership effectiveness is important in improving the

quality of services in organizations as it will be of interest to scholars in management and leadership,

specifically to health care providers. The study will extend the knowledge that currently exists in the

literature. This study will also contribute immensely to the current literature by considering leadership

effectiveness as one aspect of the broader scope of health care services.

The study will provide an understanding of the importance of leadership effectiveness toward improving

the practices, procedures, and success of the organization. Additionally, this research will help

organizations to develop leaders who can meet today’s challenges as well as provide better services to

patients. On top of that, the research will help current and future leaders to succeed in their career

development and stimulate future research on similar topics.

By providing quantitative measures of leadership effectiveness and quality health care services, the

research will provide new perspectives on the relationship between leadership effectiveness and the quality

of health care services. This study will make a significant contribution to the field of leadership

effectiveness and quality health care services given that the existing system is unsatisfactory to patients.

Scope of the study

In this research, the main purpose is to investigate the impact of effective leadership on the quality of health

care services at Universiti Sains Malaysia Hospital (HUSM), Kubang Kerian. Thus, the research is focused

on leadership effectiveness and the quality of the health care services at HUSM. This study is only limited

to the staff and in-patients at HUSM.

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Literature Review

Leadership is a process of influencing followers in order to achieve a common understanding to perform a

task and reach an organizational goal (Smith, 1996). The concept of leadership gives huge impact on the

theory and practice of organizations (Smircich & Morgan, 1982). This is because without good leadership,

many organizations will be paralyzed and disorganized. Leadership effectiveness is a vital element in

bringing organizations to success because effective leaders understand its impacts and contributions in

improving the quality of organizations (Noubar et al., 2011). Yusof and Bhattasali (2008) point out that

effective leadership has played an important role in bringing organizations closer to global standards.

Effective leadership provides leaders with skills, so that they are able to have a clear picture to meet the

challenges of the environment and create significant change in order to meet organizational goals (Center

for Creative Leadership, 2010).

McCuddy and Cavin (2008) noted that effective leaders know how to adapt to multicultural differences,

have exceptional knowledge of business operations, have effective time management skills, and be able to

act and think beyond traditional boundaries. Additionally, being an effective leader requires the ability to

take the perspective of others (McCormick, 1999). McCormick further notes that the ability to take the

perspective of others means that leaders should be able to see the world through others’ eyes.

According to Puvarattanakul and Muenjohn (2009), leaders are responsible for the success or the failure of

their organizations. Thus, to achieve their objectives and goals, the organizations must have effective

leaders, who can influence employees to work towards achieving those objectives and goals in an efficient

way. On the same note, effective leaders initiate the necessary changes in business organizations to achieve

these goals. According to Toremen Toremen, Ekinci, and Karakus (2006), a leader who wants to be

effective must employ human touch, which means using empathy in all of his or her leadership actions.

Geller (2000) noted that, effective leadership can be accomplished through empathy, regular

communication, and good interpersonal skill with employees. These criteria will help effective leaders to

give clear directions and help employees to rise above and beyond organizational practices to accomplish

difficult tasks. Effective leadership plays a vital role in sustaining the success of quality health care service.

Effective leadership is seen as a process of unifying people, developing cohesive skills, innovating, and

having supportive relationships with the people around them. These types of leaders also help people to

mobilize change (Essays, 2013).

Being effective leaders means these leaders involve everyone at every level of the organization. They know

the best approach for their staff and are able to guide them closer towards their vision. These leaders are

empathic, have shown a strong commitment, and are able to lead by example, inspiring and supporting their

teams. These leaders have also shown to be strong role models for the beliefs and values they hope others

will adopt. In a health care environment, these types of leadership skills are very important in terms of

quality. A study showed that leadership has a visible affect on the quality of patients’ health care

(Mowbray & Firth-Cozens, 2001).

Over the years, quality has become core to our daily lives. Improving the quality of health services has

become a primary concern for patients. In health care services, improving patient and employee satisfaction

leads to favorable results, positive word of mouth and positive affects of medical outcomes (Choi, 2002). In

order to provide satisfaction to patients, quality service has become increasingly important for hospitals.

Juran (1988) said that quality service nurtures customers’ confidence and is very important for a

competitive advantage. Quality also means enhancing effiency, reducing mistakes and reducing costs

(Mowbray & Firth-Cozens, 2001). Previous research states that effective leadership is positively associated

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with higher employee satisfaction and better performance and would thus improve public health care

services (Essays, 2013).

Quality service is reflected in today’s health care centers in a wide variety (Choi, 2002). Quality service

refers to clinical outcomes, services received by the patients that make a medical difference in the lives of

the patients . These medical treatments can include everything from doctor’s appointments, consultations,

treatments, procedures, and medications (Hughes, 2008). Service relates to what the medical staff can do to

make the patients’ experience better and make them feel good. Choi et al. (2002) also noted that quality

service is an important ingredient of the success of an organization based on its primary role of achieving

patient satisfaction. These include communication, response, amenities, level of empathy and the quality of

the care that they receive. The research will be determined based on three basic elements, which include the

contribution of leadership effectiveness, the quality of the service, and the satisfaction of patients and staff

of HUSM.

Leadership effectiveness and quality health care service are two essential elements in increasing the

likelihood of achieving desired health care outcomes. These elements play an imperative role in promoting

the health care of the general public and reducing potential threats to health such as infectious diseases and

environments. Furthermore, improving the quality of health care services has became as top priority on the

list of hospitals and government agenda. These elements will enhance the chances of patients getting access

to the best possible health care services and resources in Malaysia.

Methodology

The study was conducted at the teaching university known as “Hospital Universiti Sains Malaysia”

(HUSM) located in Kubang Kerian, Kelantan, Malaysia. The researcher visited in-patients and employees

at the hospital to distribute the questionnaire. The researcher met the in-patients and staff individually and

explained the purpose of the research. The research was using a quantitative method. The study used a

cross-sectional research design. In this case, it used two types of survey instrument. To measure leadership

effectiveness for the doctors, nurses and administrations, the research was using the Leadership Practices

Inventory (LPI) survey developed by Jim Kouzes and Barry Posner (2000). For the in-patient survey, the

research was using a widely used questionnaire, the Consumer Assessment of Health Care Providers and

Systems or CAHPS. CAHPS is developed by the U.S Department of Health and Human Services (1995).

Mrs. Nor Aini from Universiti Sains Malaysia’s Language Center has validated the instruments that will be

used in the research. The research will be done by selecting doctors, head nurses and administrators and in-

patient groups from the selected wards. Survey questionnaires were used to obtain information on patients’

and employees’ satisfaction in health care plans.

Sample

The sample consisted of hospital staff and patients who received inpatient services from different wards.

This sample size is selected based on the top five wards that received the highest amount of patients. The

selected wards are the female medical ward, the male medical ward, antenatal wards, and the male surgical

ward. The sample was categorized as a non-interventional study. It was a purposive sampling which

focused on a selected group in order to answer the research questions.

Vulnerability/Protection of participants’ rights

The patients and staff who were willing to participate in this study are protected according to the federal

requirements specified by the Department of Health and Human Services’ Code of Regulations,

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IRB00004494. Accordingly, the research protocol for the study was reviewd by the University Sains

Malaysia Research and Ethical Committee. The study strictly follows all the guidelines needed in order to

protect participants’ rights and vulnerability. The researchers are committed to follow all the guidelines. As

participants, they:

1. Have enough time to decide whether or not they wish to be in the research study and to make that
decision without any pressure from the people who are conducting the research.

2. Can refuse to be in the study and/or to stop participating at any time.
3. Will be told what information the study is attempting to attain, and what they will be asked to do in the

study.

4. Will be told about the reasonably foreseeable risks of being in the study.
5. Will be told about the possible benefits of being in the study.
6. Will be told whether there are any costs associated with being in the study.
7. Will be told who will have access to the information collected and how their confidentiality will be

protected.

8. Will be told whom to contact with questions about the research and about their rights as a research
subject.

9. The participants will not be asked to write down their names on the survey form.
10. Staff group- only for those who are working at the selected wards. Privacy and confidentiality will be

guaranteed. It will definitely have no effect in the yearly performance.

Sample size calculation

According to Glenn D. Israel (2015), for the purpose of the study and population size, three criteria are

needed to determine the appropriate sample size. The criteria are: the level of confidence, the level of

precision, and the degree of variability in the attributes being measured. In this study, for the level of

confidence , a 95% confidence level is selected. The level of precision, also known as sampling error, is ±5

percent (100-95%), which is the range the true value of the population is estimated to be. The degree of

variability is 0.05, which indicates the maximum variability in a population. Each of these are reviewed

below:

N = N is the population size.

e = the level of precision.

The total number of the participants was 805. Out of 805, 407 were HUSM staff and 398 were patients.

Statistical and Data Analysis

Data Collection

The data will be collected at one time point within one to two weeks. The researchers will visit the selected

wards and explain the study to the participants. After brief interviews with the patients and staff, the

participants will complete the survey form. The patients will complete the CAHPS survey and the staff will

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complete the LPI survey form. The surveys will use the 5-point Likert Scale, where 1 = Strongly Diagree

and 5 = Strongly Agree. The collected data will be labelled and stored in a secured file by the primary

researcher to ensure confidentiality.

The Result

The preliminary analysis was conducted which included the frequency analysis, factor analysis, reliability

analysis and descriptive analysis. Frequency analysis is used to gather information on the respondents’

profile, factor analysis and reliability analysis is conducted to measure the reliability and quality of the

instrument used in this study while descriptive analysis is conducted to examine the respondents’

perceptions toward the variables of the study (leadership effectiveness and service quality).

Profile of HUSM Employees

The result showed that the majority of the HUSM employees who participated in this study are female

(69.5%). Most of them are from 26 to 35 years old (42.9%). Out of 406 respondents, the majority of them

are Malay (92.9%), followed by Chinese (5.9%), others (1%) and Indian (0.2%). As for educational

qualification, the majority of the respondents have a high school diploma and associate degree or equivalent

(43.8%).

Profile of HUSM Patients

The result showed that most of the HUSM patients involved in this study are female (73.2%). The majority

of them are from 26 to 35 years old (33.2%). Out of 396 respondents, the majority of them are Malay

(92.9%), followed by Chinese (3.7%), Indian (0.5%) and others (0.2%). As for educational qualifications,

the majority of the respondents have a high school diploma or equivalent (44.6%).

Referring to Table 1, the KMO value of 0.927 and the significant result of Bartlett’s Test of Sphericity

shows that the data did not have multicollinearity problems and the correlation between the items is

sufficient to perform the factor analysis.

Table 1: KMO and Bartlett’s Test

Kaiser-Meyer-Olkin Measure of Sampling Adequacy. .927

Bartlett’s Test of Sphericity Approx. Chi-Square 6769.810

df 351

Sig. .000

The study has two variables which were leadership effectiveness as the independent variable and service

quality as the dependent variable. The results of the reliability analysis in Table 2 indicated that both

variables have good and strong Cronbach’s Alpha values which was more than .90. This result shows that

the instrument used in this study is reliable.

Table 2: Reliability Analysis

Variable Cronbach’s Alpha No. Of Items

Leadership Effectiveness .944 13

Service Quality .933 14

The results showed that leadership effectiveness was correlated significantly with the service quality (p <

0.05). However, the relationship between the two variables is very weak (r = 0.103). In Table 3, leadership

effectiveness, service quality as well as overall service quality was perceived as high by the respondents.

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Table 3: Mean Scores and Standard Deviation for the Study Variables

Variables Mean Standard Deviation Results

Leadership Effectiveness 4.24 0.545 High

Service Quality 4.31 0.550 High

Overall Score of Service Quality at HUSM 8.17 1.467 High

The patients were asked to indicate their perception towards HUSM overall service quality based on the

scale from 1 (very low) to 10 (very high). The result showed that 99.2%, majority of respondents were

satisfied with the services. Very little chose lower than scale 5 (0.8%).

The Spearman’s Rho Correlation analysis was conducted in the study. The results showed that leadership

effective correlated significantly with service quality (p < 0.05). However, the relationship between the two

variables is very weak (r = 0.103). Based on the result of simple linear regression, the result showed that

there is no relationship between the independent variable (Leadership Effectiveness) and dependent

variable (Service Quality). This showed that there are other predictors that affect the quality of services at

HUSM.

Conclusion

Leadership effectiveness is an important tool for organizations in order to inspire, mobilize, communicate

and motivate their followers to reach the organizational goal. Leadership effectiveness means great leaders

with certain skills do what it takes to accomplish any goals that they set in their minds in order to improve

the quality of the services for the benefit of the staff, the customers and the organization itself. Quality of

health care service relates to promoting and enhancing health care services, increasing efficiency and

patient outcome, and reducing mistakes and costs.

This study revealed that the employees perceived their leader to have high leadership values especially in

terms of encouraging a sense of cooperation in the workplace, treating the employees with respect and

courtesy and having a good relationship in the workplace. Meanwhile, the HUSM patients reported that

they received high quality healthcare service from the HUSM staff especially in terms of professionalism

and great attitude of the HUSM staff, satisfaction with the treatment given and things being explained in a

way that is easily understood. Based on the correlation analysis, this study found that there is a correlation

between leadership effectiveness and service quality. However, the relationship is very weak.

Acknowledgement

The author would like to thank Universiti Sains Malaysia for making the research possible under The

Short-Term grant (Grant no. 304/PJJAUH/6313205).

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Emergency medical services core competencies: a Delphi study

Article  in  Australasian Journal of Paramedicine · July 2019

DOI: 10.33151/ajp.16.688

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01

Research
Emergency medical services core competencies: a Delphi study
Talal AlShammari MSc(CritCare), PhD Candidate and Lecturer1; Paul A Jennings PhD, Clinical Manager2; Brett Williams PhD, FPA is
Professor and Head of Department2

Affiliations:
1Department of Emergency Medical Care, College of Applied Medical Sciences, Imam Abdulrahman bin Faisal University, Dammam,
Saudi Arabia
2Department of Community Emergency Health and Paramedic Practice, Monash University, Victoria, Australia

https://doi.org/10.33151/ajp.16.688

Abstract
Introduction
The emergency medical services (EMS) education in Saudi Arabia has evolved considerably during the past decade and this rapid
improvement has seen a disparity of educational approaches. Therefore, a core competency framework which aligns with the
requirements of Saudi EMS education should be identified and accommodated. The aim of this study was to obtain professional
group consensus on the desirable core competencies for EMS Bachelor degree graduates in Saudi Arabia in order to develop a core
competency framework for Saudi Arabian EMS.

Methods
A two-round Delphi method using a quantitative survey with a purposeful sampling technique of expert information-rich participants was
used. The instrument comprised 40 core competency statements (rated on a 1-10 Likert scale, with 1 being ‘not important at all’ and 10
being ‘extremely important’) and an open-ended question. An international systematic scoping review and local national review informed
the items in this study.

Results
At the end of the second round, the response rate was 70%, and the sample demonstrated diversity in terms of qualifications, expertise
and discipline. All core competencies achieved a majority and stability in the first and second rounds. Core competency items achieved
the 75% consensus requirement.

Conclusion
This study provided consensus on 41 core competencies specific to Saudi EMS industry requirements. However, the findings do
not represent a definitive blueprint model for alignment into EMS curricula. Further research and statistical modelling for the core
competencies are highly recommended.
Keywords:
attributes; competence; EMS; paramedic; Saudi Arabia
Corresponding Author: Talal AlShammari, tmaalshammri@iau.edu.sa

02

Introduction
While the history of emergency medical services (EMS)
in Saudi Arabia dates back to 1934 (1), educationally and
academically the system remained stagnant for more than
70 years. In the past decade, however, the education of EMS
has been revolutionised: first, with the development of local
EMS diplomas, whereby paramedics were trained to provide
advanced life support (ALS) care to patients; and second, by
the replacement of diplomas in 2012 with Bachelor degrees,
according to recommendations made by the World Health
Organization (2).

Starting in 2007, Bachelor degree programs were developed
either indigenously or in collaboration with other established
universities, such as Flinders University in South Australia.
Saudi Arabia has one of the most established EMS academic
training programs (3), and currently offers over 10 university
or college Bachelor degree programs (1). However, a diversity
of educational approaches between the different universities
and colleges is evident (1) and this inconsistency between
academic programs risks the development of a mismatch
between educational output and industry competency
requirements specific to Saudi Arabia.

Such disparity of educational approaches can also result
in variation in terms of how graduates from different
EMS programs manage and communicate with patients,
particularly as paramedic guidelines and medical oversight are
fundamentally restrictive in managing the range of pre-hospital
contexts and circumstances and levels of medical ambiguity
(4). Furthermore, the delivery of adequate and safe patient
care by paramedics is reliant on competence in making critical
decisions about the incident scene, safety concerns, available
equipment, the patient’s condition and other complex aspects
of pre-hospital care. As such, identifying the correct core
competencies and applying them to EMS educational programs
will facilitate the progression of competent EMS graduates into
the workforce and the improvement of overall patient care.

Author contributions
Talal Alshammari: study conception, collated and analysed
data, provided statistical assistance and helped write the paper.
Paul Jennings: study conception, and helped write the paper.
Brett Williams: study conception, discussed core ideas to study,
and helped write the paper.

Methods
Study design
This study utilised a Delphi method, a quantitative survey
technique that gathered the opinions of selected experts in the
field of Saudi EMS with the aim of obtaining group consensus
on the desirable core competencies for EMS Bachelor degree
graduates. According to Crutzen (5) where there is scarcity

of scientific knowledge on a certain topic, it is useful to adopt
the Delphi method. This is particularly relevant in the context
of Saudi Arabia, where a relatively small disciplinary field,
geographical distance and a lack of anticipated conferences
and scientific gatherings means there is limited scope for
EMS experts to meet face-to-face. The anonymity of a Delphi
study is also conducive to merit-based responses and limits
the effects of peer pressure (6). The iteration of a Delphi study
was conducted to give the experts opportunity to amend their
responses between rounds.

Setting
The surveys were distributed and returned using an internet-
based Qualtrics questionnaire, which was delivered to
participants via email. Ensuring participants’ anonymity was
crucial as it enabled them to freely divulge their professional
judgements on the topic. The survey was sent to participants
on an individual basis to ensure their identity remained
anonymous and email addresses were protected. Individual
responses were received via Qualtrics for collection by the
researcher, thereby adding another layer of anonymity (7).

Participants
As expert information-rich participants were the target sample,
a purposeful sampling technique was utilised. There are
generally no specific guidelines for choosing experts in the
Delphi method (8). However, there are three general criteria
for eligibility as a Delphi participant: 1) that participants hold
a relevant degree and have the requisite background and
experience in the field (to meet this criterion in the current
study a minimum qualification of Bachelor degree was set);
2) participant’s willingness to contribute to the study; and 3)
a willingness to review the initial judgements with the aim of
attaining study consensus (8,9). It is important to acknowledge
that the expert selection method utilised may be subjective.

The expert participants on the Delphi study panel comprised
two main groups. The first group represented the 10
academic EMS programs in Saudi Arabian universities and
colleges and were targeted for their specific perspectives
on academic practice, student concerns, research and,
ultimately, the core competencies they deemed would best
serve the Saudi EMS system. The second group of 10 experts
represented industry stakeholders from the different hospital
and EMS providers, and occupied leadership, clinical and
administrative positions. This group also included one of the
few Saudi female paramedic leaders. This group of experts
represented the different fields involved in Saudi EMS provision
including disaster management, emergency medicine, quality
management, EMS training, accreditation and medical and
operational supervision. The literature on the Delphi method
recommends 10 to 18 expert participants (10) therefore 20
individuals were invited to participate in the study to allow for
drop-outs between Delphi rounds and those who declined to
participate (11).

AlShammari: EMS core competencies
Australasian Journal of Paramedicine: 2019;16

03

AlShammari: EMS core competencies
Australasian Journal of Paramedicine: 2019;16

Instrumentation
Before delivering the instrument via the Delphi process, a
pilot face and content validity study was undertaken. Validity
measures an instrument’s scientific utility, specifically how well
an instrument measures what it purports to measure (12). The
study involved the nomination and sending of invitations to
eight academics from various health professional disciplines
involved in EMS education and research. The instrument was
prepared in English and the nominated participants included
two native Arabic speakers who were fluent in the English
language. Several amendments were performed based on the
participants’ feedback.

The purpose of the Delphi study was to produce a Saudi-
specific EMS core competency instrument, which is the result
of an international scoping review (13) and a review of Saudi
national EMS Bachelor programs (1). The first part of the
survey comprised seven demographic questions which included
gender, age, qualification, experience, medical discipline,
professional role and nationality. The second part comprised 40
core competency statements rated on a 1-10 Likert scale where
1 represents ‘not important at all’ and 10 represents ‘extremely
important’. Finally, an open-ended question was added: ‘If there
is another core competency statement that you think is missing,
please write it here’. The survey was amended following each
round. This is an important advantage of the Delphi technique
as the sequential nature of Delphi questionnaire rounds permits
modification of the study instrument between rounds (14).

Procedures
First round
The 20 prospective expert participants were contacted by
email via a Qualtrics software anonymous link, and consent to
participate in the study was implied by their accessing of the
Qualtrics email link and completion of the survey. One week
after the initial email, a follow-up reminder email was sent, after
which the first round of the study concluded.

Feedback report
Of the 20 expert prospective participants contacted, 17 agreed
to participate in the study. All participants completed the
entire survey and five participants responded to the optional
open-ended question. Following a review of comments by the
authors a decision was made to add another core competency
item, ‘be able to demonstrate English language proficiency to
an adequate level for appropriate professional communication’,
to reflect the fact that English is the medical language used in
Saudi Arabia. Another item regarding disaster preparation and
management was amended to include the phrase ‘and terrorist
incidents’, based on input from three of the expert participants.
Two other responses were disqualified for the following
reasons:
1. Statement: ‘health advocacy for the community’ was already

included under item 13, ‘be able to provide health and social
advocacy responsibly’.

2. Statement: ‘be able to maintain personal wellbeing and
fitness’ was already included under item 32, ‘understand
the need to maintain an appropriate level of physical and
mental fitness’.

The statistical feedback report was made up of seven
categories as follows: minimum, maximum, central tendency
(mean), level of dispersion (standard deviation), variance, count
(frequency) and the number and percentage of responses
to each of the item levels. The feedback report omitted
the demographic information and was limited to collective
responses to ensure anonymity of the participants during the
collection process. The adopted consensus level was 75%,
as per the recommendation of Keeney (15). While all core
competency statements reached consensus above 75%, the
statements were included in the second round of the Delphi
survey to allow participants an opportunity to change their
opinion based on the feedback report and personal judgement.
Moreover, since only one new statement was generated and
one amendment made, carrying all statements through the
entire Delphi process represented best practice (16).

Second round
The feedback report from the first round was emailed to
participants together with an invitation to complete the second
round of the Delphi study. The response rate fell to 14, and
only one response was received to the open-ended question
to generate new or missing core competency statements. The
generated statement ‘be familiar and friendly to a multi-cultural
society in hospitals, companies and Hajj’ was disqualified as
it was already included under item 2 ‘be able to practise with
respect and non-discriminatory manner’.

Data analysis
Delphi method consensus varies between different studies both
statistically and in the use of terminology; some include post
hoc figures while other studies assign specific ranges that vary
from 51-80% or utilise other techniques (6,9). In the current
study, the established 75% item consensus was adopted and a
systematic procedure for Delphi termination was adopted from
Dajani (17), where the basic tenets of the procedure are as
follows:
• Consensus: complete and unanimous agreement between

the participants
• Majority: more than 50% agreement between participants
• Bipolarity: when there is an equal divide between

participants
• Plurality: the agreement of the largest subgroup between

the respondents
• Disagreement: when each participant has differing views

from all other respondents.

04
AlShammari: EMS core competencies
Australasian Journal of Paramedicine: 2019;16

Another approach to testing consensus and stability is
proposed by Scheibe (18), where the basic aim is to achieve
a state of equilibrium between each iteration and a marginal
change of less than 15% for each Delphi item. The survey data
was exported from the Qualtrics software into a Microsoft Excel
spreadsheet for analysis.

Ethics
Consent was implied when participants opened the Qualtrics
email link and they completed the survey electronically.
Approval from the Monash University Human Research
Ethics Committee was granted on 28 February 2017, and the
study ascribed project number 8072. In addition, the Saudi
Red Crescent Authority granted approval on 18-5-1438 Hijra,
equivalent to 15 February 2017, project number 81211.

Results
As presented in Table 1, a diverse range of qualifications,
expertise and disciplines was found among the expert
participants.

In accordance with established Delphi stability and agreement
criteria, Dajani (17) all core competency statements achieved
a majority in each round. Moreover, all core competency
items (whether original, new or modified) surpassed the 75%
consensus requirement (Table 2) (15). All items in this study
achieved the Scheibe (18) criteria, with the highest marginal
difference in item 36 at 9.1% change between the two rounds.
All items demonstrated an increase in the level of consensus
between rounds, with a minimum increase of 0.2% for item 9,
and indicated the highest level consensus possible. (16)

The initial round generated five statements with a new core
competency and an amendment, while the second round
only generated one disqualified statement which therefore
indicated stability (19). In order to maintain research rigor, a
70% response rate is considered the minimum recommended
rate (16). In the current study, the response rates in the first and
second rounds were 85% (17 out of 20) and 70% (14 out of 20),
respectively. It was therefore anticipated that the response rate
would fall below 70% if another round was introduced (20,21).

Discussion
The findings demonstrate that the Delphi technique is an
effective methodology for establishing consensus in the
development of EMS core competencies. Within health sector
research, there is evidence of the Delphi method’s usefulness
as expert knowledge in the different disciplines is held by a
group of recognised field experts (7). Moreover, educational
research has sometimes depended on the use of the Delphi
method, especially for curriculum outcome development. In the

context of conducting the current study, the method has proved
useful in overcoming the major disadvantages of nominal group
techniques, including senior expert dominance, geographical
distance and difficulty in reaching consensus (22).

Complete consensus was obtained in this study and all results
were shown to be stable between rounds. The choice of
consensus percentage was decided before data collection as it
was expected that all items would be considered important for
the newly established Saudi EMS educational system (1).

Table 1. Demographic information
Category First

round
Second
round

Gender Male 16 13
Female

1 1

Total 17 14

Age group (years) 18-28 1 1
29-39 10 9
40-49 6 4
50 or above 0 0
Total 17 14

Highest
qualification

Certificate 0 0
Diploma 0 0
Bachelor degree 6 5
Master degree 8 7
PhD 3 2
Total 17 14

Years of EMS
experience

1-4 3 3
5-9 4 3
10 or more 10 8
Total 17 14

Primary medical
discipline

Paramedic 9 8
Nurse 2 2
Physician

5 4

Respiratory care 1 0
Total 17 14

Main professional
role

Administrative/
leadership

11 9

Education/
academic

5 4

Clinical/patient
care

1 1

Total 17 14
Nationality Saudi 15 13

Egyptian 1 1
Jordanian 1 0
Total 17 14

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AlShammari: EMS core competencies
Australasian Journal of Paramedicine: 2019;16
Table 2. List of core competencies for both rounds

First round Second round
Item Mean Std Mean Std
Be able to practise within the legal and ethical boundaries of the profession (Item 22) 9.59 .69 9.64 .61
Be able to maintain appropriate and effective safety procedures (Item 23) 9.59 1.19 9.64 .48
Be able to practise with respect and non-discriminatory manner (Item 2) 9.41 1.09 9.64 .48
Be able to conduct appropriate decision making and critical thinking (Item 9) 9.41 1.46 9.43 .49
Be able to provide appropriate and effective clinical care (Item 8) 9.35 1.23 9.79 .56
Be able to work as part of a team in a collaborative and professional approach (Item 3) 9.18 1.38 9.64 .61
Have the ability to take patient history and conduct examination and assessment of both adults and children
(Item 24)

9.18 .86 9.50 .63

Be able to conduct appropriate scene management (Item 25) 9.18 .98 9.57 .49
Be able to effectively communicate information verbally and non-verbally to patients, colleagues and others
(Item 1)

9.12 1.18 9.43 .82

Be able to demonstrate English language proficiency to an adequate level for appropriate professional
communication (Item 41)

– – 9.07 .96

Be able to maintain good coping skills to deal with stressful situations (Item 20) 8.94 .87 9.21 .56
Be able to demonstrate a high level of understanding for practice standards and protocols (Item 35) 8.94 1.00 9.21 .67
Be able to conduct themselves to a high professional behavioural standard (Item 19) 8.88 1.41 9.43 .61
Have the theoretical knowledge of key concepts in the EMS profession (Item 7) 8.82 1.82 9.14 .99
Be responsible for the quality of patient care (Item 18) 8.82 1.46 9.57 .73
Be able to maintain the appropriate personal characteristics of being trustworthy and accountable (Item 26) 8.82 1.10 9.50 .50
Be able to problem-solve by assessing professional issues and calling upon the required experience and
knowledge to resolve them (Item 10)

8.76 1.35 9.29 .59

Be able to maintain situational awareness at all times, whilst working in unpredictable situations (Item 11) 8.76 1.39 9.21 .77
Be able to maintain appropriate patient interaction and welfare of patients (Item 16) 8.76 1.11 9.29 .88
Be able to work as autonomous professionals with high levels of personal professional judgement (Item 28) 8.76 1.11 9.29 .70
Be able to work with different equipment and technology within the scope of practice (Item 32) 8.76 1.63 9.43 .62
Be able to maintain accurate and comprehensible record keeping within the scope of practice (Item 33) 8.76 1.52 9.14 .74
Be committed to a process of continuous lifelong learning and professional development (Item 21) 8.65 2.08 8.86 .83
Be able to reflect on their own experience and practise as professionals (Item 15) 8.59 1.19 9.29 .59
Be able to maintain an appropriate level of training through different professional courses (Item 30) 8.59 1.14 8.93 .88
Understand the need to maintain an appropriate level of physical and mental fitness (Item 31) 8.59 1.42 9.14 .64
Be able to manage personal emotions and those of patients and relatives (Item 12) 8.53 1.29 9.00 .76
Be able to provide mentoring and education when training others (Item 14) 8.53 1.88 8.64 1.11
Be able to provide care according to evidence-based practice (Item 17) 8.53 1.68 9.36 .72
Be able to work in different transportation modes (Item 29) 8.53 1.04 8.64 1.23
Be able to practise with appropriate Islamic values (Item 38) 8.53 2.23 9.29 1.33
Be able to maintain involvement with public and community health (Item 39) 8.41 1.42 8.64 .89
Be able to effectively practise in Umrah and Hajj (Item 40) 8.41 2.40 8.50 1.76
Be able to conduct an appropriate level of professional quality management (Item 34) 8.35 1.78 8.93 .80
Be able to demonstrate leadership skills (Item 5) 8.29 1.67 8.64 .89
Be able to provide health and social advocacy responsibly (Item 13) 8.24 1.31 8.86 .74
Be able to demonstrate an understanding of new technologies for clinical practice (Item 37) 8.24 1.93 8.86 .64
Be able to effectively supervise students and colleagues (Item 6) 8.18 1.76 8.21 1.21
Be information literate, by having the capacity to search and apply information (Item 4) 8.12 1.97 8.79 .56
Be flexible in learning from different sources including guidance from other colleagues (Item 27) 7.94 1.89 8.79 .77
Be able to prepare for and manage disasters and terrorist incidents (Item 36) 7.88 2.35 8.79 1.21

06

AlShammari: EMS core competencies
Australasian Journal of Paramedicine: 2019;16

As the core competency statements were extracted, clustered
and duplicates removed from previously published literature
reviews (1,13), the initial Delphi round for item generation was
removed. Therefore, the study concentrated on the following
two Delphi rounds to achieve item consensus.

The expert participants overall ratings were high. However, five
core competency statements emerged as the most important
for Saudi EMS, namely legal and ethical practice, safety
procedures, respect and non-discrimination, decision making
and critical thinking and clinical practice. These results both
converge and diverge from previous research in other EMS
industries. When looking at the first concept of legal and ethical
practice, an obvious similarity is with attributes from Australian
graduates (23). However, in the United Kingdom study by
Kilner (24) the same law and ethics concept was ranked only
30th in mean rank for paramedics. The importance of law and
ethics can be seen in the study by O’Brien (25) and the UK
Health and Care Professions Council (26) which established
an entire dimension for ethical and legal responsibilities,
consisting of four and eight statements, respectively. Legal and
ethical EMS practice in Saudi represents the most important
core competency, especially considering the nascent nature of
the profession and the need to establish the associated legal
structures.

Safety procedures were the second most important core
competency for Saudi EMS. Safety is the first step in any
interaction between paramedics both before and after arrival
at a scene. Although not highly rated by UK paramedics (24),
or adequately researched within the field of EMS, safety
remains a mandatory tenet of any professional EMS governing
association (26-29).

Respect and non-discrimination were also important concepts
for Saudi EMS in a country with a multi-cultural population,
especially during Hajj and Umrah. According to Spencer (30),
‘health outcomes deteriorate when health professionals do not
provide care that is culturally appropriate’. The concept not
only affects patient interaction, but also other team members
in their dealings with one another (31). As the workforce in
Saudi Arabia is multi-national, educational curricula should
accommodate the need for training and simulation which
represent societal needs.

Decision-making and critical thinking was rated as the fourth
most important core competency. This result was anticipated,
as a previously conducted international literature review
identified the same concept as the fourth most studied or
endorsed core competency by eight different publications
and professional EMS associations (13). Moreover, in the
context of pre-hospital care, making critical decisions involves
considerable cognitive and mental skills (24). In addition,
the clinical duties of paramedics include many factors such
as working in an exposed pre-hospital environment and, in
particular, managing cases which the paramedic has never

dealt with before (32). Making critical decisions in the context of
Saudi EMS is more holistic than simply providing clinical care
(33). Therefore, educational curricula and simulation should
involve other facets of pre-hospital care such as the police, civil
defence and trauma centres.

Competence in clinical practice is central to being a pre-
hospital care provider and is considered a critical facet of
all EMS providers (34). Moreover, the importance of clinical
competence in paramedic practice is highly rated (23,24).
Unlike other core competencies, clinical practice is well
established in educational curricula, (24) especially when
conducted with appropriate internships (25,32). There is,
however, a need for all other important core competencies to
be accommodated in EMS curricula and training.

Following the findings of this Delphi study, it is recommended
that future research involves a national study of Saudi Arabian
EMS in which a larger sample size is statistically modelled.
This would generate a competency framework model which
best portrays the specific needs of EMS in Saudi and other
countries.

While the Delphi methodology is an accepted research
technique that has been practised for more than 50 years, (35)
the methodology has been criticised for its limitations, primarily
difficulties in generalising the results to the larger population.
Small sample size is a common factor in Delphi studies (36).
Due to the nature of Delphi studies, timing and logistical
restraints, patient perspectives were not included in this study.

Conclusion
This is the first study that represents the views of key experts
and stakeholders in Saudi EMS with the aim of reaching
consensus on a core competency framework. The Delphi
study achieved the required recommendations for majority,
consensus, stability and response rate. The findings represent
core competencies expected for paramedics in Saudi Arabia.
However, the study results do not offer a definitive blueprint for
the formation of EMS curricula. Further research and statistical
modelling based on larger samples is recommended to develop
a complete core competency model for adoption into university
curricula.

Acknowledgement
An acknowledgement of gratitude to all the Saudi EMS industry
experts who participated in the conduct of this study.

Conflict of interest
The authors declare no competing interests. Each author of this
paper has completed the ICMJE conflict of interest statement.
Brett Williams is an Associate Editor of the Australasian Journal
of Paramedicine.

07

AlShammari: EMS core competencies
Australasian Journal of Paramedicine: 2019;16

References
1. AlShammari T, Jennings P, Williams B. Evolution of

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3. Caffrey S, Barnes, L, Olvera D. Joint Position Statement on
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competence: a narrative review with practice implications.
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tool: issues and analysis. Int J Forecast 1999;15:353-75.

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8. Oh KH. Forecasting through hierarchical Delphi. Ohio: Ohio
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10. Okoli C, Pawlowski S. The Delphi method as a research
tool: an example, design considerations and applications.
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12. Nunnally J, Bernstein I. Psychometric theory. New York:
McGraw-Hill 1994.

13. AlShammari T, Jennings P, Williams B. Emergency medical
services core competencies: a scoping review. Health
Professions Education 2018;4:245-58.

14. Thompson L. A pilot application of Delphi techniques to the
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15. Keeney S, Hasson F, McKenna H. Consulting the oracle:
ten lessons from using the Delphi technique in nursing
research. J Adv Nurs 2006;53:205-12.

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in nursing and health research. Chichester: John Wiley &
Sons; 2011.

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18. Scheibe M, Skutsch M, Schofer J. Experiments in Delphi
methodology: Addison-Wesley; 1975.

19. Holey E, Feeley J, Dixon J, Whittaker V. An exploration
of the use of simple statistics to measure consensus

and stability in Delphi studies. BMC Med Res Methodol
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graduate research. Journal of Information Technology
Education 2007;6:1.

21. Van Zolingen S, Klaassen C. Selection processes in a
Delphi study about key qualifications in senior secondary
vocational education. Technol Forecast Soc Change
2003;70:317-40.

22. Delbecq A, Van de Ven A, Gustafson D. Group techniques
for program planning: a guide to nominal group and Delphi
processes. Glenview, IL: Scott, Foresman; 1975.

23. Williams B. Graduate attributes and the professionalisation
of Australian paramedics: an empirical study. Monash
University; 2011.

24. Kilner T. Desirable attributes of the ambulance technician,
paramedic, and clinical supervisor: findings from a Delphi
study. Emerg Med J 2004;21:374-8.

25. O’Brien K, Moore A, Hartley P, Dawson D. Lessons about
work readiness from final year paramedic students in an
Australian university. Australasian Journal of Paramedicine
2013;10(4).

26. Health and Care Professions Council. Standards
of proficiency for paramedics. London: HCPC;
2014. Available at: www.hpc-uk.org/assets/
documents/1000051CStandards_of_Proficiency_
Paramedics

27. Paramedic Association of Canada. National occupational
competency profile for paramedics. Ottawa: Paramedic
Association of Canada; 2011. Available at: http://pac.
in1touch.org/uploaded/web/documents/2011-10-31-
Approved-NOCP-English-Master

28. Paramedics Australasia. Paramedics Australasia
Competency Standards for paramedics. Melbourne: PA;
2011. Available at: www.paramedics.org/content/2011/10/
PA_Australasian-Competency-Standards-for-paramedics_
July-20111

29. The Council of Ambulance Authorities. Paramedic
professional competency Standards. Wellington: The
Council of Ambulance Authorities; 2010. Available at: http://
caa.net.au/~caanet/images/documents/accreditation_
resources/Paramedic_Professional_Competency_
Standards_V2.2_February_2013_PEPAS

30. Spencer C, Archer F. Paramedic education and training
on cultural diversity: conventions underpinning practice. J
Emerg Primary Health Care 2006;4(3).

31. Ford R, Webb H, Allen-Craig S, Goodwin V, D’Antonio J,
Lofts C. A simulated wilderness exercise: the development
of relational competence in paramedic students. Journal of
Paramedic Practice 2014;6:574-83.

32. O’Brien K, Hartley P, Dawson D, Quick J, Moore A. Work
readiness in paramedic graduates: what are employers
looking for? International Paramedic Practice 2013;3:98-
104.

08

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References (continued)

33. Shields A, Flin R. Paramedics’ non-technical skills: a
literature review. Emerg Med J 2013;30:350-4.

34. Tavares W, Bowles R, Donelon B. Informing a Canadian
paramedic profile: framing concepts, roles and crosscutting

themes. BMC Health Serv Res 2016;16:477.
35. Dalkey N, Hemler O. An experimental application of

the Delphi method to the use of experts. Manage Sci
1963;9:458-67.

36. Schmidt R, Lyytinen K, Keil MP. Identifying software project
risks: an international Delphi study. J Manag Inf Syst
2001;17:5-36.

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https://www.researchgate.net/publication/334288268

Assessing the pre-hospital care preparedness to face mass
casualty incident in Saudi Arabia in 2017-2018

Maged S. Alotaibi, MPH, Anas A. Khan, MBBS, MHA.

1032

ABSTRACT

األهداف: تقييم االستعداد في الرعاية )MCI( قبل املستشفيات
في اململكة العربية السعودية وحتديد وإبراز نقاط الضعف والقوة في

التأهب ملواجهه الكوارث.

املنهجية: تعتبر هذه دراسة حتليلية كمية وصفية ، وتشمل جميع
جميع في منطقة 13 في السعودي األحمر الهالل هيئة فروع
أنحاء اململكة.و مت استخدام النسخة املعدلة من )SRCA( لتقييم

االستجابة حلاالت الطوارئ واستعداد اجلاهزية في هذه الدراسة.

النتائج: مت العثور على أكبر عدد من سيارات اإلسعاف والسيارات
مكة حصلت وقد الرياض. تليها املكرمة مكة منطقة في الطبية
الكبير. استعدادهم يعني وذلك نقاط أربع على واملدينة املكرمة
ومع ذلك، كان املدينة أفضل من مكة في املقارنة ومت العثور على
الرياض في محدود التأهب كان حيث .)p=0.019( كبير فرق
واملنطقة الشرقية. أيضا، ووجد ايضًا عالقة اإليجابية املعتدلة بني
و r=0.656 درجات املتوسط العام وعدد األطباء وجدت مع قيمة

.p=0.015

اخلالصة: إن استعداد هيئه الهالل االحمر السعودي جوهري على
نطاق أداة التقييم املستخدمة في هذه الدراسة. في منطقتي مكة
جدا جيد السعودي األحمر الهالل هيئة استعداد يعتبر واملدينة،

بشكل عام ملواجهة حادثة اإلصابات اجلماعية.

Objectives: To assess the mass casualty incident (MCI)
preparedness of pre-hospital care providers in Saudi
Arabia and to identify and highlight their strengths and
weaknesses when responding to MCIs.

Methods: This cross-sectional descriptive quantitative
analysis was conducted between January 2017 and 2018
and included all Saudi Red Crescent Authority (SRCA)
general administration branches in 13 regions in Saudi
Arabia. The modified version of the emergency medical
specialists (EMS) incident response and readiness
assessment (EIRRA) tool was used in this study.

Results

: The Makkah region has the largest number of
ambulances and medics vehicles, followed by Riyadh.

Makkah and Al Madinah Al Munawarah obtained a
median score of 4 and showed substantial preparedness
for MCIs. However, Al Madinah Al Munawarah showed
higher level of MCI preparedness than Makkah, and a
significant difference was found (p=0.019). By contrast,
Riyadh and the Eastern region showed limited MCI
preparedness. In addition, a moderate positive correlation
was observed between the overall median scores and the
number of physicians (r=0.656 and p=0.015).

Conclusion: The SRCA showed substantial preparedness
in Makkah and Al Madinah Al Munawarah. The SRCA
were highly prepared to face MCIs.

Saudi Med J 2019; Vol. 40 (10): 1032-1039
doi:10.15537/smj.2019.10.24292

From the Disaster Management (Alotaibi), Saudi Red Crescent
Authority, and from the Department of Emergency Medicine (Khan),
College of Medicine and University Medical City, King Saud
University, Riyadh, Kingdom of Saudi Arabia.

Received 24th March 2019. Accepted 26th May 2019.

Address correspondence and reprint request to: Dr. Maged S. Alotaibi,
Department of Disaster Management, Saudi Red Crescent Authority,
Riyadh, Kingdom of Saudi Arabia. E-mail: rooq_622@hotmail.com
ORCID ID: orcid.org/0000-0003-3783-9195

Saudi Med J 2019; Vol. 40 (10) www.smj.org.sa OPEN ACCESS

Disaster can occur anytime and anywhere. The multiple causalities impact quality of life of
several individuals and also burden the healthcare
system.1 It primarily affects people’s health and financial
well-being.2 In 2015, several major incidents occurred
in Kingdom of Saudi Arabia (KSA). Approximately
2,000 people were left injured due to a natural disaster,
while 1,200 were affected due to a manmade disaster.3
Health status gradually declines during a disaster, and
the community requires outside assistance for smooth
functioning.4

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Assess pre-hospital care preparedness for MCI … Alotaibi & Khan

Mass casualty incident (MCI) has been described
as any incident that affects a significant number of
people.5 During MCI, the primary consideration is not
the number of casualties but the surging capacity of the
medical system to meet the healthcare needs of victims
in this situation.6 Emergency medical service (EMS)
personnel plays a crucial role in managing disasters
for over 35 years.7 For this reason, their roles have
been strengthened by the national association of EMS
physicians in all the disaster cycle phases: mitigation,
preparedness, response, and recovery.8

Mass casualty incident planning should include
the proper distribution of resources by a push or pull
model; push involves the distribution of all resources to
the community, while pull involves the centralization
of resources in the foremost place, and the patient
is pulled to the central infrastructure.8 The level of
preparedness varies in every community; some of
the communities have response capabilities, while
some lack response capabilities.9 Moreover, planning
is essential for achieving a good outcome through
successful management of disasters. Therefore, leaders
must address the questions to ensure readiness and
proper planning.10

In 2007, 56 passengers on board a motor coach
to Telluride, Colorado, passed through the Phoenix
Arizona route. When the driver took the right side of
the road, the motor coach suddenly swerved and rolled
over resulting mass casualties: 9 passengers died, and 43
sustained minor to serious injuries.11 In January 2004,
13 cargo tankers crashed into 4 small cars, resulting
mass casualties. In 2008, an MCI occurred in Mexican
Hat, resulting 53 casualties.12 After that, the National
Transportation Safety Board recommended that “the
preparedness, readiness, and response system of the
Federal Interagency Committee of Emergency Medical
Services (FICEMS) should be evaluated and then a
new guideline for EMS response to disaster conditions
should be set and implemented to all states”.11

In 2003, a study conducted to assess the public
schools’ preparedness to face MCI, and 307 schools
in Arkansas were surveyed to evaluate their level of
preparedness. Approximately 51.3% of school districts
reported that they had not established a plan for
managing MCI. On the contrary, 72.2% of school
districts planned to conduct an emergency lockdown,
while 91.2% planned to do an emergency evacuation.13

A previous study was conducted in 13 private
hospitals in KSA to evaluate their level of preparedness.
A total of 12 (92.3%) hospitals showed preparedness
for external and internal disasters. Of them, 9 (69.2%)
made an agreement with other hospitals to accept
more patients, whereas 4 (30.8%) had no interhospital
agreements. Moreover, disaster preparedness exercises
and training have not been conducted in hospitals in
the last 12 months.14 A recent study was conducted
in KSA to evaluate the level of MCI preparedness in
airports. This study showed that the airports have a
sufficient number of EMS personnel who can respond
to MCIs. However, within a relatively short period of
time, they might n. level of preparedness to face MCI.
Moreover, for pairwise comparisons across regions, the
Mann-Whitney-Wilcoxon test was used. The Statistical
Package for Social Sciences, version 21 (IBM Corp.,
Armonk, NY, USA) software was used to run these
statistical tests

A total of 12 (92.3%) hospitals showed preparedness
for external and internal disasters. Of them, 9 (69.2%)
made an agreement with other hospitals to accept
more patients, whereas 4 (30.8%) had no interhospital
agreements. Moreover, disaster preparedness exercises
and training have not been conducted in hospitals in
the last 12 months.14 A recent study was conducted
in KSA to evaluate the level of MCI preparedness in
airports. is study showed that the airports have a su
cient number of EMS personnel who can respond to
MCIs. However, within a relatively short period of time,
they might need help from the government agencies.15

Only a few studies have examined the status of
EMS in pre-hospital settings to determine their level
of preparedness during MCI or disaster situations. To
the best of our knowledge, we did not nd previous
publications studying prehospital preparedness in Saudi
Arabia. is study aimed to determine the level of readiness
and preparedness of hospitals in KSA to provide pre-
hospital medical care for MCI between 2017 and 2018.

Methods. This study was a cross-sectional descriptive
quantitative analysis. e EMS Incident Response and
Readiness Assessment (EIRRA) tool was used in this
study. is tool was designed by the United States National
Association of State Emergency Medical Services O cials
(NASEMSO) to determine the level of preparedness for
MCI. e latest edition was used during the study period.
e executive director of NASEMSO, was contacted to
request permission for the modi cation of EIRRA so it
can be applicable in KSA. e modi ed copy was reviewed
and approved by 5 experts before the implementation.
e EIRRA tool includes 7 benchmarks: personnel,
infrastructure, emergency care system, public awareness

Disclosure.

Authors

have no conflict of interests, and the
work was not supported or funded by any drug company.

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Saudi Med J 2019; Vol. 40 (10) www.smj.org.sa

and noti cation, evaluation, mass casualty planning, and
governance. ere are 31 indicators under all benchmarks.
Each indicator has sub-indicators. Each sub-indicator is
assessed using the following rating scale: 0=unknown,
one=none, 2=minimal, 3=limited, 4=substantial, and
5=comprehensive. Moreover, this tool was distributed
to all Saudi Red Crescent Authority (SRCA) general
administration branches in 13 regions in KSA.

The permission to conduct this study from SRCA
had been obtained. Moreover, this study was approved
by the King Saud Research Ethics Committee.
Before the study was conducted, each participant was
contacted by phone, and the purpose of the study was
brie y described. Consent was obtained after explaining
the importance of their contribution.

Statistical analysis. A descriptive analysis of the mean
and median values was conducted. Non-parametric tests
were the only statistic methods used to identify if there
was a signi cant di erence between SRCA 13 branches
in terms of level of preparedness to face MCI around
KSA. In this study, the Kruskal-Wallis test was used to
determine if all 13 regions had signi cant di erences in
terms of level of preparedness to face MCI. Moreover,
for pairwise comparisons across regions, the Mann-
Whitney-Wilcoxon test was used. Statistical Package for
Social Sciences, version 21 (IBM Corp., Armonk, NY,
USA) software was used to run these statistical tests.

Results. The demographic data were as follows: the
total number of centers, operation centers, dispatchers,
ambulance drivers, EMT, EMS, field supervisors,
physician, ambulance, and non-ambulance response
vehicles in each region. These data varied per region.
Riyadh, Makkah, Eastern region, and Al Madinah Al

Munawarah have the highest numbers, while the North
borders have the lowest numbers as summarized in
Table 1 and Figure 1.

The average number of centers is 33.5 centers.
Figure 2 shows the number of centers in each region.
Riyadh has the largest number of centers (89 centers,
21%). Makkah and Eastern regions have 3 operation
centers, while the remaining regions only have one
operation center.

The average number of dispatchers is 30.7. Riyadh
has the largest number of dispatchers (n=87), while
Aljof and Albaha regions have the smallest number of
dispatchers (n=15). The average number of ambulance
drivers is 34. Riyadh and Makkah have the most
significant number of ambulance drivers, whereas
Najran has the lowest number of ambulance drivers.

The average number of EMTs is 354.3. Riyadh and
Makkah have the largest number of EMTs, while the
North borders have the lowest number of EMTs.

The average number of EMSs is 13.5. Riyadh and
Makkah have the largest number of EMS, while Aljof,
Tabuk, Albaha, and Najran have the lowest number of
EMS. Moreover, there are no EMS in the North borders
and Jazan regions.

The average number of physicians is 12.9. Riyadh
has the largest number of physicians (n=54) followed
by Makkah (n=46), while Najran, Albaha, Aljof,
Jazan, and North borders have the smallest number of
physicians (n=1).

The average number of ambulance cars is 67.7.
Makkah has the largest number of ambulance cars
(n=168, 19%) followed by Riyadh (145, 16%) and
Eastern region (n=120, 14%). By contrast, Hail (n=30,

Table 1 – The demographic data of 13 regions.

Name of
region

Center
Operations

center
Dispatchers Driver EMTs EMS

Field
supervisors

Physicians
Ambulance

cars
Non-ambulatory

response cars
Riyadh 89 1 87 93 1206 53 10 54 145 12
Makkah 84 3 38 90 950 40 13 46 168 13
Eastern Region 61 3 52 56 257 20 13 30 120 8
Asir 35 1 22 30 328 10 5 2 69 3
Al Madinah 31 1 43 36 400 14 5 20 62 5
Tabuk 24 1 24 27 245 4 5 5 52 1
Alqasim 23 1 23 30 250 15 5 4 54 3
Jazan 19 1 20 12 200 0 4 1 40 0
Najran 15 1 27 5 198 5 5 1 50 7
Aljof 14 1 15 17 160 1 7 1 28 0
Albaha 14 1 15 17 140 5 5 1 30 0
Hail 14 1 17 15 141 8 5 2 30 1
North border 12 1 17 14 131 0 5 1 32 0
Grand total 435 17 400 442 4606 175 87 168 880 53

EMTs – emergency medical technician, EMS – emergency medical specialists

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Assess pre-hospital care preparedness for MCI … Alotaibi & Khan

3%) and Albaha (n=30, 3%) have the lowest number of
ambulance vehicles followed by Aljof (n=28, 3%).

Illustrated in Table 2, the median scores for each
benchmark as well as the overall median scores across
all regions in KSA. Makkah and Madinah obtained a
median score of 4, which indicated that their emergency
medical system is substantially equipped to manage
MCIs. Riyadh, North borders, Eastern region, Tabuk,
Jazan, Hail, and Qasim obtained a median score of 3,
which indicated that their emergency medical system
has limited capabilities to manage MCIs. The remaining
regions obtained a median score of 2, which indicated
that their emergency medical system has minimal
capabilities to manage MCIs.

Moreover, for the entire country, the results showed
that the median for all benchmarks is the same (3)
except for the evaluation benchmark, which is 2. This

finding indicates that there were no differences between
the benchmarks across all regions in KSA.

Furthermore, the result of 5 areas (North, South,
Central, East, and West) were analyzed. The West region
has a median score of 4, which indicated that their
emergency medical system is substantially prepared for
managing MCIs. The East, Central, and North regions
have a median score of 3, which indicated that their
emergency medical system has limited capabilities to
manage MCIs. While the South region had a median
score of 2, which indicated that their emergency medical
system has minimal capabilities to manage MCIs.

The correlation between the overall median scores
of each indicator for all regions and the demographic
variables are presented in Table 3. Results exhibited
that a significant correlation was observed between the

Figure 1 – The distribution of centers in Saudi Arabia (5 areas).

Figure 2 – Number of centers per region.

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Assess pre-hospital care preparedness for MCI … Alotaibi & Khan
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overall median scores and the number of physicians in
the center (r=0.656 and p=0.015).

There was a statistical difference in the level of MCI
preparedness of the emergency medical system between
Makkah and Riyadh regions (p=0.038). Moreover,
to determine which region has higher levels of MCI
preparedness, a one-tailed test was performed and
showed a p=0.019. This finding indicates that Makkah
has higher levels of MCI preparedness than Riyadh.

There is significant difference in the level of
MCI preparedness between Makkah and the Eastern
region (Table 4, p=0.038). Moreover, to determine
which region has higher level of MCI preparedness, a
one-tailed test was performed and showed a p=0.019.
This finding suggests that Makkah has higher levels of
MCI preparedness than the Eastern region.

There was a statistical difference in the levels of MCI
preparedness of the emergency medical system between
Makkah and Al Madinah Al Munawarah regions
(p=0.038). Moreover, to determine the level of MCI
preparedness of the emergency medical system in each
region, a one-tailed test was performed and showed
a p=0.019. This finding suggests that the emergency
medical system in Al Madinah Al Munawarah has higher
level of preparedness for MCI than that in Makkah.

Furthermore, there was a statistical difference in the
level of MCI preparedness of the emergency medical
system between Riyadh and Al Madinah Al Munawarah
(p=0.038). There was a statistical difference in the
level of MCI preparedness of the emergency medical
system between West and East regions (p=0.026).
Additionally, there was a statistical difference in the
level of MCI preparedness of the emergency medical
system between West and South and West and Central
regions (p=0.001).

There were no statistical differences in the level of
MCI preparedness of the emergency medical system
between the East and Central regions (p=0.259).
However, there was a statistical difference in the level
of MCI preparedness of the emergency medical system
between the East and South regions (p=0.011).

There were no statistical differences in the level of
MCI preparedness of the emergency medical system
between the East and North regions (p=0.259) and
between the Central and South regions (p=0.073).
There were no statistical differences in the level of MCI
preparedness of the emergency medical system between
the Central and North regions (p=1) and between the
South and North regions (p=0.073).

Table 2 – The emergency medical specialists incident response and readiness assessment results in 13 regions.

Region Personnel
100

Infrastructure
200

Emergency care
system 300

Public awareness
and notification 400

Evaluation
of 500

Mass causality
planning 600

Governance
700

Overall median
score

Makkah 3 4 4 4 3 4 4 4
Riyadh 3 3 3 3 2 3 3 3
Al Madinah 4 4 4 4 4 4 3 4
Aljof 3 2 2 2 3 2 4 2
Asir 4 3 2 2 2 2 2 2
Eastern Region 3 3 3 3 2 4 4 3
Tabuk 3 3 2 3 3 3 3 3
Albaha 3 3 2 4 2 1 1 2
Najran 3 1 2 1 2 2 2 2
Jazan 3 2 3 2 3 3 1 3
Hail 3 3 3 4 3 4 4 3
Alqasim 3 3 3 3 2 3 2 3
North border 3 3 3 4 2 3 3 3
Grand median 3 3 3 3 2 3 3 3

Table 3 – Correlations between the overall median score for each benchmark and demographic variables (N=13).

Variables Center Operation center Dispatcher Driver EMT EMS Supervisor Physicians
Ambulance

cars
Medics

cars
Spearman’s rho

Correlation coefficient 0.428 0.410 0.528 0.471 0.481 0.393 0.182 0.656* 0.504 0.410
Significance (2-tailed) 0.144 0.164 0.064 0.104 0.096 0.184 0.551 0.015 0.079 0.164

*The correlation was significant at the 0.05 level (2-tailed). EMT – emergency medical technician, EMS – emergency medical specialists,

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Assess pre-hospital care preparedness for MCI … Alotaibi & Khan

Discussion. Saudi EMS students reported low
perception of and attitudes toward their preparedness
for disaster management. To assess the level of MCI
preparedness of EMS in KSA, quantitative research is
carried out. The findings in this study can be used as a
reference to identify the causes of variations in the level
of MCI preparedness among the 13 SRCA branches
in KSA. Therefore, it will help in improving the
preparedness level. The results of this study were divided
into 2 parts: demographic results and assessment results.

The distribution of ambulance center and
ambulance deployment is affected by the population
and size of each region.16 The 2 regions with the largest
number of centers, as shown in Figure 1, were Riyadh
and Makkah. According to the 2016 Saudi statistical
report, Riyadh and Makkah had the highest population
among other regions.17 In Makkah and the Eastern
regions, both had the highest number of operation
centers. The SRCA organizational chart showed that
both regions were divided into 3 units. Makkah region
divided into 3 units; Holy Capital unit, Taif unit; and,
Jeddah unit when Estern Region divided into AL Ahsa
unit, Hafr Albateen Unit and Eastern region unit Each
of these units had an operation center connected to
the main operation center in both regions with the
highest population. To operate an ambulance center,
sufficient human resources are needed. Riyadh had
the highest number of ambulance centers, which can
be affected by the population size. The SRCA used the
following 3 criteria to locate a new ambulance station:
population size, medical records, which may support
the demographic results suggesting that Riyadh had
more ambulance stations and personnel than other
regions.18 On the contrary, deployment of ambulance
should minimize the population’s transportation cost.16
Makkah had higher number of ambulance vehicles
than Riyadh as shown in Table 1. This can be due to the
preparedness programs offered during Hajj and Umrah
seasons, which are the largest annual religious mass
gatherings in the world, and the KSA government has
provided great attention to these programs.19

In the first benchmark, the entire KSA garnered a
score of 3, which indicates lack of personnel. The limited
number of EMS personnel might be due to the small
number of paramedic graduates, as reported in Alaniz’s
study.20 In 2012, diploma programs were no longer
offered in KSA. In order to become an EMS personnel,
one should finish a bachelor’s degree in paramedical
science as a minimum requirement.21 Moreover, EMS
personnel are trained on how to respond to MCIs.
Alshamrani,22 reported that the SRCA only offered
limited trainings to all EMS personnel, and they were
asked to perform daily routine work such as basic life
support, advanced cardiac life support, pre-hospital
trauma life support, and international trauma life
support. This finding supports the results of previous
studies, which reported that the EMS personnel in KSA
lacked training in disaster management.22 The medical
directors are among the important key players in MCI
management, should develop guidelines, and must
participate in disaster preparedness planning.23 Saudi
Red Crescent Authority lacked EMS consultants who
can supervise the day-to-day work of all EMS personnel
and assess disaster conditions. In this study, there was
a moderate positive correlation between the overall
median scores and the number of physicians in the
center, which indicates a lower personnel benchmark
score. Infrastructure was the second benchmark and
one of the important factors in incident management.
Infrastructure was determined in overall with limited
score. Makkah and Al Madinah Al Munawarah were
found to have substantial level of MCI preparedness
due to the programs conducted during Hajj and Umrah
seasons in these regions. In 2014 (1435 AH), a joint
operation room was established during the Hajj season.
All emergency agencies participated by sending one
dispatcher to work there, and 911 was the universal
number used for emergency calls.3,19,24 The emergency
care system benchmark had a lower overall median
score. The results of Alsadhan’s study,25 were similar to
those reported in this study and suggested that the Saudi

Table 4 – Ranks and statistical tests †,‡ (Makkah-Eastern region) N=14.

Region Number
Mean
rank

Sum of
ranks

Mann-Whitney U 15.500

Makkah 7 8.79 61.50 Wilcoxon W 43.500
Eastern region 7 6.21 43.50 Z −1.217
Total 14 asymptotic significance(2-tailed)

0.223

Exact significance [2*(one-tailed sig.)] 0.038‡

† Grouping variable: region, ‡ Not corrected for ties, sig – significance, *multiplication

http://www.smj.org.sa/index.php/smj/index

1038

Assess pre-hospital care preparedness for MCI … Alotaibi & Khan
Saudi Med J 2019; Vol. 40 (10) www.smj.org.sa

pre hospital care system need to improved. Moreover,
Makkah and Al Madinah Al Munawarah were superior
than other regions in terms of public awareness and
notification and had a higher score in the public
awareness benchmark than the remaining regions,
which can be attributed to the programs conducted
during Hajj season. Saudi Red Crescent Authority
had a lower score in the evaluation benchmark, which
examines whether the area has an effective evaluation
system that can be used to provide a thorough review
of the performance of emergency responders during
MCIs. Myers,26 reported a few evidence and measures
to review in the EMS performance system. Moreover,
a study conducted by Alsadhan,25 showed that the
evaluation system in KSA has limited capabilities to
assess the status of pre hospital medical care. Riyadh
obtained an overall median score of 3, which indicates
that this region had limited preparedness to handle
MCIs. Riyadh is the most populous region in the
KSA, with an estimated population of 8,002,100.17
A study conducted in 2011 in the United States of
America showed that New York City has limited MCI
preparedness. It has a total population of 8,244,910 and
has the same status with Riyadh.17,27,28

Additionally, the Eastern region obtained a low
score in the overall assessment. It is an important energy
industrial region in KSA, where the biggest oil company
(Saudi Aramco) in the world is located. The Eastern
region is the largest province of KSA by area, with a
total population of 4,780,619.17,29 The state of Alabama
has the same industrial status, and the total population
is very close to that of KSA’s Eastern region (4,780,135).
It obtained a low score in the same evaluation method
in the study conducted by Dia et al.27,30,31

The West region had a higher overall score, which
may be due to the preparedness programs conducted
during Hajj and Umrah seasons. The Saudi Arabian
government pays attention to the safety of people
attending the pilgrimage. Saudi Red Crescent Authority
is a member of Hajj supreme committee. It includes all
Saudi emergency agencies, and each of this organization
had to prepare a Hajj emergency plan.3,32 In this study,
Riyadh, Makkah, Al Madinah Al Munawarah, and
the Eastern region were compared, and results showed
that Al Madinah Al Munawarah was the most superior
among the regions. A significant difference was observed
between Makkah and Al Madinah Al Munawarah in
terms of level of preparedness to face MCI. Despite that,
both regions conducted the same Hajj preparedness
program. The SRCA organization chart showed that
Makkah was divided into 3 units based on its population

size. Al Madinah Al Munawarah population that might
the cause made Al Madinah Al Munawarah better than
Makkah in the preparedness to face MCI.17,18

Study limitations. Pre-hospital medical care
preparedness has not been tested before, and no baseline
data were obtained for this study.

In conclusion, the SRCA prepared well to manage
MICs in Makkah and Al Madinah Al Munawarah
regions. Riyadh, North borders, Eastern region, Tabuk,
Jazan, Hail, and Qasim had a median score of 3. The
remaining regions had a median score of 2. Some
important aspects were not discussed in this study.

Furthermore, the SRCA should encourage EMS
consultants to act as medical directors and supervise
all EMS personnel. Moreover, more physicians
should be deployed in all regions. Emergency medical
specialists personnel preparedness should be improved
by establishing a training program related to MCI. All
EMS personnel should take the incident command
system courses. Additionally, performing regular
exercises and drills for MCI at least twice a year is
important, and SRCA should take the leadership
role. Saudi Red Crescent Authority should take into
consideration the importance of implementing a unified
management and restructure of the organizational chart
in Makkah and Eastern regions. Privatization may be
one of the solutions to increase the region’s level of MCI
preparedness.

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https://www.moi.gov.sa/wps/portal/Home/sectors/4c/!ut/p/z1/jZFRb4IwFIX_Sl987gWq4GNDMouabGzBsb6QBqrpAq2Wss1_v2K2hyUTbXIfevOdc9tzMccl5lp8qINwymjR-vsbX1SQEcICEm4S8vQANA_XKU2zMInn-PUCpCvKSLwFSLarOWSUFc_LPIqARphP6He_erhyKNypv_5APm3_IjVe3xriU1DvpxOnmNdGO_nlcFmbrhO6QWONTWvaGfzTRMLOYNBqr2SDelkPVrkzMkdpLxn3qJbe0fZoGQTegKjqTrhq5F4MrauE9SnwyT-MOfwFgCYeoNGOsTgPH5PgB5ja5K0sj11RlJ_nCFR2-AbE8_cu/dz/d5/L2dBISEvZ0FBIS9nQSEh/

https://www.moi.gov.sa/wps/portal/Home/sectors/4c/!ut/p/z1/jZFRb4IwFIX_Sl987gWq4GNDMouabGzBsb6QBqrpAq2Wss1_v2K2hyUTbXIfevOdc9tzMccl5lp8qINwymjR-vsbX1SQEcICEm4S8vQANA_XKU2zMInn-PUCpCvKSLwFSLarOWSUFc_LPIqARphP6He_erhyKNypv_5APm3_IjVe3xriU1DvpxOnmNdGO_nlcFmbrhO6QWONTWvaGfzTRMLOYNBqr2SDelkPVrkzMkdpLxn3qJbe0fZoGQTegKjqTrhq5F4MrauE9SnwyT-MOfwFgCYeoNGOsTgPH5PgB5ja5K0sj11RlJ_nCFR2-AbE8_cu/dz/d5/L2dBISEvZ0FBIS9nQSEh/

https://www.moi.gov.sa/wps/portal/Home/sectors/4c/!ut/p/z1/jZFRb4IwFIX_Sl987gWq4GNDMouabGzBsb6QBqrpAq2Wss1_v2K2hyUTbXIfevOdc9tzMccl5lp8qINwymjR-vsbX1SQEcICEm4S8vQANA_XKU2zMInn-PUCpCvKSLwFSLarOWSUFc_LPIqARphP6He_erhyKNypv_5APm3_IjVe3xriU1DvpxOnmNdGO_nlcFmbrhO6QWONTWvaGfzTRMLOYNBqr2SDelkPVrkzMkdpLxn3qJbe0fZoGQTegKjqTrhq5F4MrauE9SnwyT-MOfwFgCYeoNGOsTgPH5PgB5ja5K0sj11RlJ_nCFR2-AbE8_cu/dz/d5/L2dBISEvZ0FBIS9nQSEh/

http://d-scholarship.pitt.edu/25743/

http://d-scholarship.pitt.edu/25743/

http://d-scholarship.pitt.edu/25743/

http://d-scholarship.pitt.edu/25743/

https://www.ncbi.nlm.nih.gov/pubmed/?term=Myers+JB%2C+Slovis+CM%2C+Eckstein+M%2C+Goodloe+JM%2C+Isaacs+SM%2C+Loflin+JR%2C+et+al.+Evidence-based+performance+measures+for+emergency+medical+services+systems%3A+a+model+for+expanded+ems+benchmarking

https://www.ncbi.nlm.nih.gov/pubmed/?term=Myers+JB%2C+Slovis+CM%2C+Eckstein+M%2C+Goodloe+JM%2C+Isaacs+SM%2C+Loflin+JR%2C+et+al.+Evidence-based+performance+measures+for+emergency+medical+services+systems%3A+a+model+for+expanded+ems+benchmarking

https://www.ncbi.nlm.nih.gov/pubmed/?term=Myers+JB%2C+Slovis+CM%2C+Eckstein+M%2C+Goodloe+JM%2C+Isaacs+SM%2C+Loflin+JR%2C+et+al.+Evidence-based+performance+measures+for+emergency+medical+services+systems%3A+a+model+for+expanded+ems+benchmarking

https://www.ncbi.nlm.nih.gov/pubmed/?term=Myers+JB%2C+Slovis+CM%2C+Eckstein+M%2C+Goodloe+JM%2C+Isaacs+SM%2C+Loflin+JR%2C+et+al.+Evidence-based+performance+measures+for+emergency+medical+services+systems%3A+a+model+for+expanded+ems+benchmarking

https://www.ems.gov/pdf/2011/July2011/8-EMS.Incident.Response-Readiness.Assessment.(EIRRA)

https://www.ems.gov/pdf/2011/July2011/8-EMS.Incident.Response-Readiness.Assessment.(EIRRA)

https://www.ems.gov/pdf/2011/July2011/8-EMS.Incident.Response-Readiness.Assessment.(EIRRA)

https://www.ems.gov/pdf/2011/July2011/8-EMS.Incident.Response-Readiness.Assessment.(EIRRA)

https://www.ems.gov/pdf/2011/July2011/8-EMS.Incident.Response-Readiness.Assessment.(EIRRA)

https://www.ems.gov/pdf/2011/July2011/8-EMS.Incident.Response-Readiness.Assessment.(EIRRA)

https://www.ems.gov/pdf/2011/July2011/8-EMS.Incident.Response-Readiness.Assessment.(EIRRA)

https://www.ems.gov/pdf/2011/July2011/8-EMS.Incident.Response-Readiness.Assessment.(EIRRA)

https://www1.nyc.gov/assets/planning/download/pdf/data-maps/nyc-population/acs/boro_demo_2011_acs

https://www1.nyc.gov/assets/planning/download/pdf/data-maps/nyc-population/acs/boro_demo_2011_acs

https://www1.nyc.gov/assets/planning/download/pdf/data-maps/nyc-population/acs/boro_demo_2011_acs

https://www1.nyc.gov/assets/planning/download/pdf/data-maps/nyc-population/acs/boro_demo_2011_acs

https://www1.nyc.gov/assets/planning/download/pdf/data-maps/nyc-population/acs/boro_demo_2011_acs

https://www1.nyc.gov/assets/planning/download/pdf/data-maps/nyc-population/acs/boro_demo_2011_acs

https://www1.nyc.gov/assets/planning/download/pdf/data-maps/nyc-population/acs/boro_demo_2011_acs

Authors
• Affiliation

ABSTRACT

• Introduction

Results
References