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The Role of Social Media on Talent Search and Acquisition: Evidence from Contemporary Literature

Journal of Intercultural Management

Objective: The main objective of this paper is to explore/investigate the role of social media in searching and acquiring the talented employees and the appropriate rationales behind and ways of using the social media for such purposes with due advantages and risks involved.Methodology: This paper uses the literatures published from 2010 to 2019 to highlight the research on social media influence on searching talent for organizations. For due purpose, Scopus and ResearchGate databases have been utilized to search the papers using the keywords such as social media, social networking sites, online recruitment & selection, candidate screening, hiring, human resources management and talent search.Findings: Although social media is getting popular among employers, they are not utilizing this platform as the main rather as secondary sources. LinkedIn is the most preferred source among the employers for searching and acquiring talents.Value Added: The paper is expected to contribute to the...

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See More Documents Like This

Using Social Media as a Research Recruitment Tool: Ethical Issues and Recommendations

Luke gelinas.

Petrie-Flom Center at Harvard Law School and Harvard Catalyst

Robin Pierce

Sabune winkler.

Harvard Catalyst

I. Glenn Cohen

Holly fernandez lynch.

Petrie-Flom Center at Harvard Law School, Harvard Catalyst, and Center for Bioethics, Harvard Medical School

Barbara E. Bierer

Brigham and Women’s Hospital, Harvard Medical School, and Harvard Catalyst

The use of social media as a recruitment tool for research with humans is increasing, and likely to continue to grow. Despite this, to date there has been no specific regulatory guidance and little in the bioethics literature to guide investigators and IRBs faced with navigating the ethical issues it raises. We begin to fill this gap by first defending a non-exceptionalist methodology for assessing social media recruitment; second, examining respect for privacy and investigator transparency as key norms governing social media recruitment; and, finally, analyzing three relatively novel aspects of social media recruitment: (i) the ethical significance of compliance with website ‘terms of use’; (ii) the ethics of recruiting from the online networks of research participants; and (iii) the ethical implications of online communication from and between participants. Two checklists aimed at guiding investigators and IRBs through the ethical issues are included as Appendices.

1. Introduction

Social media sites – Facebook, Twitter, Grindr, Instagram, LinkedIn, and other similar online spaces – offer various platforms for connecting and sharing interests and information, while allowing users to maintain physical separation and a degree of anonymity. For the purpose of this article, we will define ‘social media’ as internet-based applications that permit users to construct a public or semi-public profile and create and maintain a list of other users (‘friends’) with whom they may share content and participate in social interactions and networking ( Boyd and Ellison 2008 ; Kaplan & Haenlein 2010 ). With increased general use and penetration of social media platforms, investigators are exploring ways to utilize social media in research; in particular, social media is emerging as a promising way to identify and recruit potential participants for clinical trials and other forms of human subjects research ( Gearhart 2015 ). Social media is attractive in this context because it may enable investigators both to reach wider segments of the population than may otherwise be accessible and to target individuals on the basis of personal information that, in many cases, allows researchers to infer their eligibility for particular studies.

Despite its growing popularity as a recruitment tool, there is no specific regulatory guidance and few resources to guide IRBs, investigators, and others on the use of social media for research recruitment. ( Andrews 2012 ; Adair 2015 ). 2 Moreover, while some IRBs have policies on social media recruitment, most do not, and even among existent policies there is no clear consensus over how to identify and approach the most pressing issues. 3 This is problematic, since navigating social media recruitment requires applying legal and ethical norms sensitively in a context that may be unfamiliar to investigators and IRBs. In this article we examine the conceptual and ethical issues involved with the use of social media in recruitment to research and present a set of practical recommendations for investigators and IRBs. Our focus here is purposefully narrow. We limit our analysis primarily to ethical issues that arise when using social media as a method for identifying and contacting potential research participants, or as a platform for communication between currently enrolled participants, leaving aside ethical issues surrounding online research using social media more generally (e.g., data collection over social media sites) as well as issues that arise when obtaining participant consent online (e.g., online tools and methods for ensuring comprehension and confirming participant identity). We have developed the recommendations we offer into a practical guidance document for investigators and IRBs, including two checklists for facilitating proposal and review of social media recruitment, both of which are presented here as Appendices. 4

We begin with a brief overview of the empirical literature on the effectiveness of social media as a recruitment tool. In Section 2, we advance a methodology for evaluating social media recruitment proposals, grounded in the belief that social media recruitment ought to be assessed in terms of the same general ethical principles as traditional recruitment, namely, beneficence, respect for persons, and justice. However, we also analyze what we take to be the two most salient normative considerations for evaluating social media recruitment, which are more specific components of the general principles: (1) respect for the privacy of social media users, and (2) investigator transparency. In Section 3, we consider several detailed cases to illustrate our methodology, as well as the substantive application of the ethical principles we advocate. In Section 4, we examine three issues that we think are relatively unique to social media recruitment and so likely to be less familiar to investigators and IRBs: (i) the ethical significance of compliance with website business rules or ‘terms of use’; (ii) the ethics of recruiting from the online networks of current or potential research participants; and (iii) the ethical implications of certain forms of post-enrollment online communication from and between participants. The article thus has two overarching aims: to examine the issues conceptually, asking whether and in what ways social media requires a shift in conceptualizing the ethical aspects of recruiting human subjects for research; and to yield concrete, practical ethical guidance and directives for investigators and IRBs involved in proposing and evaluating social media recruitment.

1.1. Why social media for recruitment?

Recruitment to research remains a perennial challenge. By some counts, up to 60% of all clinical trials are delayed or cancelled due to lack of enrollment, slowing the progress of socially valuable research and at times resulting in research participants being exposed to risks, burdens, and inconvenience for no benefit ( Puffer & Torgersen 2003 ; Wertheimer 2013 ). Further, researchers face particular problems with specific hard-to-reach populations, such as patients with rare medical conditions, or women at particular stages of pregnancy ( Ramo and Prochaska 2012 ), among others. Additionally, traditional methods, such as use of print, radio, and television advertising, can be costly and often do not remedy low participation rates ( Fenner et al. 2012 ).

While empirical research on the effectiveness of social media recruitment is still in its infancy, several studies offer early signs of promise ( Shere et al. 2014 ; Frandsen et al. 2014 ; Akard et al. 2015 ; Goadsby 2013 ; Fenner et al., 2014; Tweet et al. 2011 ). To date social media recruitment techniques have shown effectiveness for HIV vaccine clinical trials ( Sitar et al. 2009 ), occipital nerve studies ( Goadsby 2013 ), pediatric cancer research ( Akard et al. 2015 ), depression prevention studies ( Morgan et al. 2013 ), and smoking cessation research ( Frandsen et al. 2014 ; Heffner et al. 2013 ), among others. Perhaps more striking, they have also shown effectiveness with historically hard-to-reach populations, such as young cancer survivors ( Gorman et al. 2014 ), gay Latino males ( Martinez 2014 ), the deaf community ( Kobayashi et al. 2013 ), and sufferers of low-incidence diseases, such as spontaneous coronary artery dissection ( Tweet et al. 2011 ; Ramo and Prochaska 2012 ). While unlikely to be the sole remedy for the challenges of recruitment, social media is, and will increasingly become, an important tool in the recruitment arsenal, and therefore calls for ethical and regulatory guidance that can facilitate the appropriate implementation of social media recruitment techniques.

2. Methodology and substantive ethical considerations

In this section we propose a methodology for evaluating social media recruitment proposals, and identify and discuss the substantive normative considerations that we take to be most salient in this context. As with all human subjects research, federal and state laws govern social media recruitment activities; these legal requirements do not differ when applied to social media. Because there are no specific regulations applicable to social media recruitment, we focus here on the ethics.

Before proceeding further we distinguish two basic types of recruitment activity: passive and active. Passive recruitment involves distributing recruitment materials (ads, posters, flyers) with the aim of attracting potential participants to contact the research team for more information and for consideration of enrollment. By contrast, active recruitment occurs when research staff approach and interact with specific individuals with the aim of enrolling them in research, usually on the basis of knowledge of characteristics that would make them suitable candidates for particular trials.

Both passive and active recruitment have social media and more traditional ‘off-line’ correlates. Posting flyers in subways or buses is a popular form of traditional passive off-line recruitment, while placing advertisements in health or patient support group websites is a form of passive online recruitment. Approaching an oncology patient in clinic for trial enrollment on the basis of the research staff’s knowledge of his or her disease state is an example of traditional active off-line recruitment, while emailing a member of a patient support website for breast cancer on the basis of her online activity and membership in the group is an example of active online recruitment.

2.1. Non-exceptionalism as the default

A key component of our approach is that, whether active or passive, social media recruitment should be evaluated in substantially the same way as more traditional analogue or ‘off-line’ recruitment. When planning (as an investigator) or reviewing (as an IRB) a social media recruitment technique, we propose the following strategy. First, whenever possible, identify a more familiar off-line variant or equivalent of the social media technique being proposed. Second, identify the substantive ethical considerations that bear on the off-line version and bring them to bear on the online version (see below, Section 2.2). Finally, identify any ways the online version differs from the more traditional off-line equivalent, and evaluate this difference in terms of relevant ethical norms and considerations. In short, we suggest striving to normalize social media recruitment techniques while remaining sensitive to their potentially novel aspects by, first, making their resemblance to more traditional off-line recruitment explicit; second, applying the appropriate ethical considerations and scrutiny; third, determining whether social media recruitment differs from off-line recruitment in ways that warrant further review.

There are two justifications for this non-exceptionalist approach. The first is conceptual. Like off-line recruitment, social media recruitment is governed by the foundational norms of research ethics: beneficence, respect for persons, and justice. The second reason is practical. Normalizing social media in the way we suggest, by comparing it to off-line recruitment, can help investigators and IRBs get their bearings in a context that may be less familiar and may help them isolate any aspects of social media recruitment that are potentially novel and require greater scrutiny. Ideally, this can serve to make investigators and IRBs who might otherwise be wary of social media recruitment more comfortable approaching it, which in turn can help facilitate use of this important recruitment tool. We illustrate our methodology below.

2.2. Substantive ethical considerations

While social media recruitment is governed by the same foundational norms that govern more traditional analogue recruitment, the ‘embedded’ and interconnected nature of social media does provide a new, potentially unfamiliar context for the application of these principles, one that demands sensitive application of these norms and the recognition that their operational implications may, in these contexts, differ. Our view is that the most salient ethical considerations fall into two categories: (i) respect for the privacy and other interests of social media users and (ii) investigator transparency. Because in our view ethical analysis of essentially all cases of social media recruitment involve application of both privacy and transparency considerations, we unpack both of these concepts before illustrating them in greater detail in Section 3.

2.2.1. Respect for privacy and other interests

Respect for privacy is grounded in the foundational norms of respect for persons and beneficence. The right to control sensitive personal information about one’s self, including one’s private health information, is essential for our ability to maintain a personal sphere of sovereignty where we can govern ourselves effectively (i.e., autonomy), as well as crucial for our wider well-being, given the harm that can occur (dignitary or tangible) when sensitive personal information is taken, used, or shared without our consent.

In the context of social media recruitment, respect for privacy is especially important given the amount of personal information available online and the ease with which it can be accessed. Of course, much of the personal information available online has been voluntarily made public. In light of the seemingly “public” nature of this information, it may seem counterintuitive to claim substantial privacy interests. Typically, however, this information has not been shared by social media users for the advancement of generalizable knowledge, or even health purposes, but for social connectivity and personal expression. Moreover, perceptions of whether a venue is public or private may vary ( Taylor et al. 2014 ). Posting material for social networking purposes, often within limited public communities, is different than intending for it to be available to the public in general or researchers in particular. In addition, empirical research has shown that social media users often lack knowledge of how to manage privacy settings and fail to grasp the full extent to which they render information shared over social media publicly available ( Boyd 2010 ; Madden et al. 2013 ). This may result in a ‘disinhibition effect’ ( Suler 2004 ; Swirsky et al. 2014 ) that leads social media users to act in ways that they would find embarrassing and avoid if they knew the public or researchers were observing. For example, a social media user, not realizing that her privacy settings permit people other than her family and friends to see her posts, may describe intimate and vulnerable details of her experience with an illness that she would not want the public to see. In general, social media users may not comprehend the range of possible uses, risks, and harms of posting potentially sensitive personal information online ( Parsi & Elster 2014 ; Taddicken 2013 ).

Because of this, investigators should handle personal information responsibly, even if it has already been made widely available, by minimizing the chances of individuals suffering embarrassment, loss of dignity or other harms due to social media recruitment methods. Investigators should never disclose sensitive information to others without the participant’s explicit permission, or engage in online interactions that would allow others to infer sensitive information about participants or potential participants, even if that information has already been made publicly available in a different context.

In addition to considerations of privacy, researchers have an obligation to be mindful of the values, mores, and potential vulnerabilities of those they approach on social media ( Gyure et al. 2014 ). It is possible to be respectful of privacy but nonetheless approach and communicate with different online communities in ways that are offensive or insufficiently sensitive to their condition. While researchers have similar obligations in off-line recruitment, the quickness and ease of online communication, the physical distance between researchers and investigators during online interactions, and the fact that many social media users may not expect to be approached by researchers over social media, make sensitivity to the interests and vulnerabilities of potential participants particularly important when recruiting over social media.

2.2.2. Transparency

The second salient ethical consideration in the context of social media recruitment is investigator transparency. The importance of transparency is grounded primarily in respect for persons, which, outside of exceptional circumstances, demands investigator truthfulness and honesty when interacting with research volunteers. Transparency also serves a dual function by promoting public trust in the research enterprise, which is needed for research to flourish. 5

Transparency requires investigators engaged in recruitment activities to be truthful and honest when describing the aims, details, risks, and benefits of studies. In the context of social media recruitment the demand for transparency has further implications. The first stems from the fact that certain social media venues, such as online patient support groups, may require users of the site to have certain characteristics as a condition of joining and participation. An online patient support group for breast cancer survivors, for example, may require members to actually be breast cancer survivors themselves, or to be a close family member of a breast cancer survivor, in order to join the site. Since investigators may lack the relevant characteristics, these sites may often be technically closed to them. Transparency in this situation requires investigators to avoid deception and refrain from fabricating online identities to gain access to these online communities, instead seeking access through alternative mechanisms, such as asking for explicit permission from a moderator or site administrator, as is discussed further below.

A second issue related to transparency concerns the obligations of investigators to proactively disclose their presence on social media when collecting information for recruitment purposes. Such information gathering can often be done relatively easily and without the knowledge of social media users, but there is a distinctive concern about whether activity of this sort may be insufficiently respectful of social media users —counting as cases of researchers ‘creeping’ or ‘lurking’ on a site where users reasonably expect that such activity will not occur and to which social media users could justifiably object. The question is whether, or under what conditions, investigators must alert social media users to their presence and purpose when viewing and collecting the personal information of strangers.

In our view the answer to this question depends largely on whether the site is reasonably viewed as a public or private space. The more public a social media venue is—that is, the fewer restrictions there are on who may join, and the easier it is for one to join without providing personal or identifying information—the less of a reasonable expectation of privacy users of the site have, and the less of an obligation investigators have to proactively disclose their presence. That said, we think it wise for investigators to err on the side of caution in this context. Even if social media users do not have a right that investigators proactively announce their presence in all contexts, the perception of researchers ‘creeping’ or ‘lurking’ may damage public perception and trust in ways that hinder recruitment and set back the progress of research more generally.

In this section we provide concrete illustrations of respect for privacy and investigator transparency, and our approach to evaluating social media recruitment generally, by considering several cases. The cases are intended to highlight both the methodology we recommend as well as how to bring the substantive ethical considerations just discussed to bear on social media recruitment.

Investigator A wishes to recruit from a Facebook cancer patient support group to increase enrollment for her clinical trial, which holds the prospect of direct benefit for participants. The Facebook support group is ‘open,’ that is, there are no restrictions to joining the support group, no registration, no requirement to post certain minimal information, and no assumption of privacy or that all members online are afflicted with cancer. Anyone, including the research team, can identify and contact members of the group through it. Some members of the IRB wonder whether contacting people in this way would be ethically advisable, given that the group is formed around a disease category and not specifically geared toward clinical research, and that members of the group are likely to be vulnerable and may feel embarrassed, stigmatized, or alienated by recruitment advances.

The methodology we advocate first instructs us to find a more familiar off-line variant of this situation, such as a physician-investigator in a clinical setting attending an open oncology patient support group in order to make members aware of the opportunity to participate in a trial. In the latter situation, an IRB might appropriately advise the investigator to seek permission to attend the support group in order to protect patient privacy and preserve trust. Indeed, some online group settings have a moderator from whom permission may be sought. However, in at least some cases (e.g., some Facebook groups) there is no identifiable moderator from whom to seek permission. Further, in online settings such groups are often less personal and intimate, and less continuous; the nature of the group is more fluid and individuals can easily choose not to respond, unlike at in-person support groups where the person is physically present and may feel compelled to respond. These differences might justify fewer or less stringent restrictions from the IRB in the online variant. The IRB might, for example, recommend that investigators access the group through a moderator, if available, without explicitly requiring it. Or they might require the investigator to record any negative comments or information shared from Facebook members, tabulate that information, and report back to the IRB at continuing review or earlier.

In terms of substantive ethical considerations, transparency dictates that investigators be forthright that they are accessing the group in their capacity as researchers, not patients, as well as about the aim and details of the study, its risks and benefits, and so on. With respect to privacy, investigators should protect the personal information of the site’s members. They should refrain from disclosing anything that would allow personal health information to be inferred about members of the group, including the fact that they are in or are eligible for the research in question, even if those individuals choose to disclose this information in certain contexts.

With respect to the concern about whether recruitment overtures would be sufficiently sensitive to this population, some members of the site may indeed feel annoyed or embarrassed by recruitment advances. But this by itself does not make recruitment unethical. The important question is whether user annoyance is based on a reasonable expectation that would be violated by the recruitment activity. The answer to this question may vary from case-to-case. One way for social media users to have reasonable expectations is for a website policy to make clear that the site is to be used expressly and only for purposes that do not include recruitment or research. But this is not the only way. Some types of recruitment overtures might be so lacking in tact or taste as to conflict with common and reasonable expectations in society at large, even if no website policy prohibits them. For example, approaching a Black Lives Matter Facebook group about a study on race and IQ, or a support group for parents of recently deceased young children about the effects of family tragedy on divorce rates, may conflict with widespread and reasonable norms of propriety and decency and violate reasonable expectations of these users.

That said, we think that such cases are rare, even when the people approached are sick or the situation is sensitive. In particular, while recruiting over a Facebook page for cancer sufferers requires sensitivity, it does not, we would argue, demand that researchers forego all contact with the group but rather that they be transparent, respectful, and sympathetic to their circumstances and possible suffering, making sure potential participants understand that they will be allowed to accept or reject the offer freely, without pressure or undue influence from the research team. It is also important that, while some members of this group may feel embarrassed, stigmatized, or upset by recruitment advances, others may welcome the opportunity to participate in clinical research that can improve treatment and indeed holds the prospect of direct benefit for them.

Investigator B wishes to use online ‘banner ads’ to deliver customized messages for specific individuals or groups based on their online activity, to increase targeted recruitment for his clinical trial. In the first instance, he wishes to place banner ads on a Facebook media group for expectant mothers. In the second instance, he wishes to use banner ads to deliver customized online messages for specific individuals or subgroups of individuals based on their search and browsing history, online profile information, and the like.

Methodologically, the first step is to ask whether and how these examples differ from the familiar practice of strategically placing flyers in physical spaces likely to be frequented by the potential study population (e.g., placing flyers for a study on depression in pregnancy in obstetrical offices). One difference is that the social media site is, while the obstetrical office is not, tracking and keeping a record of who looks at the ad or expresses interest in it. Does this difference demand greater IRB scrutiny? We would argue that the answer is a qualified ‘No.’ Having one’s response to online ads collected and tracked is a feature of social media use generally . So long as the tracking and data mining activities of a site (what will be tracked, by whom, for what purpose, and so on) are publicly disclosed to potential users before they agree to join, which they typically will be as part of the ‘terms of service,’ people concerned about such activities can make informed decisions about whether to join.. That said, if the research team intends to track responses to their ad in ways that would not normally occur over Facebook, the IRB would have an obligation to review the risks associated with this form of tracking and, if appropriate, ensure participant protections are in place prior to the initiation of the research (which protections may include additional notification to the participant), since these risks would now exceed the background risks associated with social media use generally. 6

A second cluster of differences arises for using customized banner ads to target individual pregnant women, given that these ads utilize personal online activity and search history in ways that placing a poster in an obstetrical clinic does not. The main concern with using customized banner ads is whether they can be employed by researchers in ways that are sufficiently respectful of privacy. However, the personal search information on which these ads are based is part of an algorithm used by the site or advertising company and is generally not shared with investigators directly. Because of this, the use of banner ads will typically not involve additional research risks for potential participants and indeed will be analogous to other off-line recruitment strategies, such as the growing use of algorithms to scan medical records to identify patients who may be eligible for particular studies. So long as the algorithms on which online banner ads are based comply with applicable law, and investigators receive none of the information used to target individuals, they should be evaluated in the same way as more familiar off-line strategies. In other words, the IRB should affirm that no information relating to an individual’s online activity will be collected and retained by the investigator, and that the language of the banner ad proposed is appropriate prior to approval.

A final possible difference is that some people may find the targeting of individual pregnant women via customized banner ads “creepy,” or “creepier” than the targeting of pregnant women generally at an obstetrical office. It is doubtful that the mere perception of creepiness has intrinsic ethical weight or would demand greater protection for social media users. Nonetheless, it may lead to negative public sentiment and erode public trust in the research enterprise—which investigators and IRBs certainly have reason to avoid. That said, while the perceived creepiness of customized research ads and their relation to public trust are empirical questions, it seems to us that the widespread (and still growing) popularity of social media platforms—despite the fact that targeting of various types is prevalent over social media, and perceived by some as ‘creepy’—suggests that the risk of online targeted ads significantly undermining public trust is relatively low.

If, as we have argued, the differences just discussed do not give rise to greater research risks in the online scenarios, the IRB should review them using customary norms and methods. For example, if placing posters in an obstetrician office requires permission of the doctor, which it presumably would, then posting an advertisement on the website might require permission of a moderator or other authority connected with the site.

Investigator C is a clinical investigator conducting HIV research. To expedite enrollment, he considers using a location-based social and dating application directed towards gay and bisexual men. The platform’s terms of service put no restrictions on who may or may not join, and are silent on whether the application may be used for research purposes, neither prohibiting nor expressly permitting it. Investigator C downloads the application to his smartphone, where he creates a profile that gives him access to information from other users, and observes that User M has a profile identifying him as age 29, gay, HIV+, and living in zip code 77777. This information suggests that User M may satisfy the eligibility criteria for Investigator C’s clinical trial. Investigator C wonders if it would be permissible for him to contact User M to see if he is interested in enrolling in the protocol.

The first thing we should ask is whether targeting users of this application differs from other methods of seeking out the relevant population, such as, for instance, approaching individuals leaving a bar frequented by gay men. One way these two activities may differ is in the degree of certainty investigators have about whether the individuals targeted are in fact HIV+ and meet the inclusion criteria for the study. In the example above, User M has self-identified as HIV+ on his application profile, but presumably investigators recruiting outside a gay bar will typically not have knowledge of the HIV status of the people they approach. Whether there is knowledge of disease status matters ethically. Users of the application who do not self-identify as HIV+ could legitimately take offense with a researcher who assumed that they were HIV+ simply because they are using the application, as could individuals targeted for an HIV study merely on the basis of attending an establishment frequented by gay men. Could a user of the application who self-identifies as HIV+ on their profile page, as in the original example, reasonably take offense in the same way?

It could be argued that, in some cases at least, the willingness of users to disclose their HIV status or other sensitive health information may be based on an assumption that the site is restricted to romantic uses. Individuals may be willing to disclose their HIV status to potential dates, given that this is the ethical thing to do, but hesitant or unwilling to disclose it on the application if they knew researchers would also see it. If so, Investigator C might be seen as taking advantage of a context-specific willingness to disclose highly personal information in order to use that information in ways not intended by the user and to which they might object.

The weight of this objection depends in part on further details about the aim and accepted use of the specific application and whether users are in fact justified in thinking that only potential romantic partners will view their profile. Since the site requires users to disclose information and create a profile before gaining access to the profiles of others, users are reasonable to expect that there will be some limitations on who views their information and the application may not be considered as an entirely public space. If the application is exclusively advertised and used as a romantic dating service only, users may have a reasonable expectation that researchers will not view their profile. In that case researchers would have some reason (not necessarily decisive) to avoid using the site for recruitment purposes, which would need to be weighed against the value of the research and the prospects for seeing it to completion using other recruitment strategies when determining the overall ethical status of the activity.

If, on the other hand, the site is not restricted (in policy or practice) to romantic interactions—if users tend to encounter co-workers, neighbors, people who are just curious, and so on, not all of whom are looking for dates with the user—the objection is much less concerning. In many ways, researchers, who have ethical obligations not to share the user’s personal health information outside the context of research, are less threatening to the user’s privacy and interests than others to whom the user may reveal information about himself over such a platform. Perhaps more importantly, if the application is not restricted to romantic purposes, users who are concerned about their health information being viewed by people other than potential dates may easily choose not to disclose their HIV status in their profile but instead do so only in the midst of a conversation initiated by another user whose romantic intentions are clear.

In any situation, the principle of transparency would require Investigator C to make it clear to users of the application from the start that he is contacting them for the purpose of research, rather than for social reasons. Since the primary purpose of the application is to facilitate social interaction (whether romantic or not), users of the platform might justifiably feel deceived or wronged if the research team were to approach them under the pretense of social reasons only later to disclose their underlying intent of offering them participation in the study. Additionally, the application profile created by Investigator C should be accurate and not misleading.

Thus, while the objection reveals how context-sensitive evaluation of social media recruitment can be, and reinforces the need for IRBs to be sensitive and discerning in their application of privacy norms, it does not, we would argue, necessarily show that Investigator C’s proposed recruitment technique is unethical. So long as users do not have a valid expectation that researchers will not view their profile, and so long as researchers treat personal information accessed over the application discreetly and confidentially, this sort of recruitment activity can be ethically acceptable.

As these examples show, there will typically be a good deal of overlap between social media recruitment techniques and their off-line analogues. There are, however, several aspects of social media recruitment that are relatively unique to it and that deserve special attention. In the final section of this article, we identify these aspects and analyze them in terms of their ethical implications.

4. Potentially unfamiliar aspects of social media recruitment

Despite the general similarities to traditional recruitment methods, there are several aspects of social media recruitment that are relatively novel and likely to be unfamiliar to investigators and IRBs. In this final section we conclude by recommending concrete guidance on the ethical questions raised by three issues in particular: (i) website policies and ‘terms of use,’ (ii) recruiting from the social networks of current or potential participants, and (iii) managing online communication from and between participants.

4.1. Website policies or ‘terms of use’

The first relatively novel aspect of social media recruitment stems from the existence of website policies or ‘terms of use’ to which users may be asked to agree before entering a site, and to which they may be required to comply while using it, at the risk of being removed from the site and/or subject to legal consequences. Terms of use state the rules of the website on a range of possible issues, including what types of interactions are expected and tolerated on the site, how personal information shared over the site may be used, and who will have access to that information and for what purposes, among other contractual expectations. The existence of these policies demands consideration of what weight to afford them in determining what is and is not acceptable research activity. Because one function of a site’s ‘terms of use’ may be to establish legal expectations and potential liability, it will often be important for investigators and IRBs to work together with institutional legal counsel when deliberating over ambiguous or difficult cases. Here we will leave the legal issues aside and focus specifically on the ethical issues associated with terms of use.

Terms of use establish reasonable expectations among users of different sites that others have reason to honor. If, for example, a website’s terms of use require individuals to agree to refrain from certain online behaviors as a condition of using the site, users of the site can reasonably expect other users to refrain from the prohibited behaviors, and for the website to enforce its policies in cases of breach. Because of this, there should typically be a presumption in favor of researchers complying with terms of use. On occasion, however, there may be countervailing considerations, such as whether a moderator is willing to grant an exception, the site’s own behaviors and attitudes toward its stated terms of use in practice, and more generally whether there are benefits that can outweigh the risks involved with violating terms of use in particular cases.

Imagine, for example, that investigator D wishes to recruit over a patient support site, but the stated ‘terms of use’ restrict access to ‘Patients and Friends and Family only.’ However, a section of the website features prominent navigation (e.g., a dropdown panel or caption heading) for ‘Emerging and Experimental Therapies and Trials.’ In this part of the site there are numerous postings from researchers offering enrollment to members of the site, and archived posts clearly indicate that it is a well-traveled, active area. Investigator D proposes to advertise for the study in this area of the site. The study is likely to yield significant social value and Investigator D anticipates difficulty meeting recruitment targets by other means.

In all situations, we recommend that as part of the protocol submission, investigators either certify compliance with the terms of use on the sites they wish to use for recruitment or alert the IRB if their proposed recruitment techniques fail to comply with the relevant terms of use (or if it is ambiguous whether it complies with them). In this case, then, Investigator D should begin by telling the IRB that the proposed recruitment strategy is in conflict with the site’s explicit terms. If Investigator D nonetheless wishes to pursue the strategy, he should make the case that the situation is sufficiently compelling or that the benefits of the recruitment strategy outweigh the risks, here noting that the website itself is not in compliance with its own terms of use, that recruitment via other avenues is likely to be slow or ineffective, and that the study may provide significant benefit. The IRB should then determine next steps. These might include requiring the investigator to contact the moderator of the website (if one exists) to seek an exception to its stated policies, which is the ideal outcome. Alternatively, depending on the comfort level and with input from institutional counsel, the IRB may decide that the situation is sufficiently compelling to justify approving the strategy in the absence of an explicit exception.

A possible ethical concern with approving recruitment strategies that conflict with published terms of use is the lack of respect for the site itself, or the owner(s) of the site. However, such considerations are not within the purview of IRBs: the mission of the IRB is to protect the rights and interests of research participants. 7 Since the site or site’s owners are not research participants (or potential participants), it is questionable whether IRBs should refuse to approve strategies merely on the grounds that they do not show sufficient consideration for sites or site owners, rather than research participants or potential participants. This is especially the case when complying with the terms of use yields no increase in participant protection and indeed denies individuals the chance to participate in potentially beneficial research.

That said, in these cases, the institution sponsoring the research, rather than the IRB per se, may have reason to respect the site, and attend to the terms of use, which would need to be taken into account in the final analysis and judgment. This differentiation of responsibility supports obtaining institutional guidance and counsel in these cases. Additionally, there is the possibility that a website user could complain about unauthorized recruitment activity that could result in the researcher being banned from the site and have negative consequences for recruitment, which should also be considered by the investigator and IRB. In our view, however, these considerations do not support a categorical prohibition against IRB approval of recruitment techniques that conflict with stated terms of use.

4.2. Recruiting via the networks of others

The second relatively novel aspect of social media recruitment stems from the interconnected nature of social media. One key feature of social media sites is the networking of social media users with ‘friends,’ ‘followers,’ and the like. In many cases these networks can be accessed with relative ease, particularly when an initial participant was recruited using social media (but even if not), and networked individuals may share characteristics relevant for study eligibility. There are, however, risks. Most importantly, this approach risks allowing a participant’s networked ‘friends’ and ‘followers’ to infer protected and sensitive information about them, including their status as research participants or their eligibility for the research—information these individuals have a moral or legal right to keep private. Because of this, investigators and IRBs must be especially attentive to protect the privacy of current or potential participants when considering recruiting via their networks.

Indeed our view is that IRBs should require investigators either to obtain authorization from current or potential research participants before using their online network for recruitment purposes, or to enlist current or potential participants to approach members of their network directly on the research team’s behalf. Exceptions to this requirement will be warranted, however, in situations where the investigator independently identifies the relevant individuals for study recruitment without using the online network of the current or potential participant. What requires someone’s permission, in other words, is not merely recruiting their networked ‘friends’ or ‘followers’ for research—people do not generally hold a right to control who may and who may not be offered the chance to participate in research—but rather that their networked ‘friends’ or ‘followers’ are being identified and targeted using their network .

To illustrate, imagine that researchers have successfully recruited Participant E for a study involving drug use in the LGBTQ community, and now wish to use her social media network to recruit other participants for the same study. Participant E often frequents a LGBTQ bar where there is known drug use, and she sometimes posts pictures of herself and her friends at the bar on Facebook. The researchers want to use this information to contact the friends tagged in one of Participant E’s photos and offer them the chance to participate in the study.

In this case the research team has a strong obligation not to disclose Participant E’s sensitive personal information to members of her online network, such as Participant E’s current enrollment in the research protocol. Because of this, the IRB should require the research team to obtain Participant E’s permission before approaching her friends for recruitment (or potentially to enlist Participant E to approach them herself on the research team’s behalf.) Suppose, however, that the ‘friend’ sought for recruitment is also independently referred to the study by her primary care physician. In that case, the IRB should allow the research team to pursue enrollment of this individual without seeking Participant E’s permission. In other words, the mere presence of a potential participant in another current or potential participant’s social media network is not itself a barrier to recruiting that individual. The key issue is whether the social media network is directly used for recruitment purposes, or whether recruitment occurs by other legitimate means.

4.3. Online participant communication

The third potentially unfamiliar aspect of social media recruitment stems from the possibility of online communication from and between research participants. Social media decreases barriers to connectivity and can dramatically extend the prevalence and reach of communication between researchers and study participants, as well as between study participants (and potential participants) themselves. This is possible even when social media is not utilized for recruitment, but may be even more likely when it is.

Online communication may in some cases have benefits, such as when participants share their positive experiences online in ways that promote positive public perception of research and enrollment into particular studies. But there are also risks to increased participant communication. First, participants who post detailed online descriptions of their experience may jeopardize the scientific integrity of the trial by including information that threatens to un-blind themselves, other participants, or the research team. This may occur, for example, when different participants describe in-detail the interventions they are receiving or how they feel or react to investigational agents, and speculate online about what arm of the trial they are in ( Glickman et al. 2012 ; Marcus 2014 ). Second, participants posting explicitly incorrect information about the trial can undermine the understanding of other participants (and potential participants). Similarly, participants portraying their experiences in an unduly negative light may harm study recruitment and retention and thereby introduce selection bias into the trial. Finally, participants reporting their experiences with certain drugs or devices may unjustifiably influence the public perception and worth of these products ( Robins 2015 ).

The options of investigators for dealing with these types of communication are limited, given that they have no authority to control participant communications or expression short of nondisclosure agreements or termination from the study, both of which are undesirable for a variety of reasons. In our view the best approach is to take steps to educate participants of the risks posed by certain social media communications to the integrity of the study. This might involve the development of educational materials explaining how social media communications may jeopardize the integrity of the trial, or a specific request to each participant to refrain from communications about the trial that could result in un-blinding or misperception. 8 Investigators may also wish to develop a communication plan for addressing these risks, which could identify triggers (e.g., participant speculation on social media about which arm they are in) for interventions from the research team (e.g., corrections of misinformation or reminders about risks of un-blinding). While investigators do not, in our view, have an affirmative obligation to search for ill-advised online posts from participants, they do have an obligation to take steps to correct misinformation and ensure the integrity of the study, when such communications are brought to their attention.

Imagine, for example, that investigator F comes across a Twitter post related to migraines and finds that participants in his study are providing specific health information to others based on their experience in the trial, and incentivizing others to join (e.g. “Currently doing a #migraine study, this #Lupron is great. Join this study it pays and it works! #clinicaltrial”). A tweet of this nature may influence individuals to enroll on the basis of expectation of medical relief, or to misrepresent themselves in order to appear eligible for the trial and receive compensation. It may also threaten to un-blind the research team or other participants. When the integrity of a trial is jeopardized by the dissemination of misleading information, investigators and research institutions have a strong interest in correcting it. In such cases the investigator should post a reminder that the trial is in progress and that this type of speculation can damage the integrity of the trial. Such communication could be part of the IRB-approved communications plan, or may require an amendment to authorize this and similar communications during the trial.

5. Conclusion

The prevalence and popularity of social media is only likely to grow, and with it, the appeal of using social media as a recruitment tool. In this article we have presented a non-exceptionalist methodology for assessing social media recruitment, examined respect for privacy and investigator transparency as two key norms governing social media recruitment, and analyzed three relatively novel aspects of social media recruitment. These efforts, and the appended guidance and checklists, offer important contributions to filling the gap between the growing use of social media in recruitment and the lack of regulatory guidance and bioethical literature on this topic, and will, we hope, make it easier for investigators, institutions, and IRBs to navigate the ethical and regulatory issues. While the ethically relevant differences between social media and more customary recruitment techniques should not be exaggerated, these materials can help to serve as a roadmap for its potentially unfamiliar aspects and contribute to putting social media recruitment in proper ethical perspective as a valuable recruitment tool.

Acknowledgments

We are grateful to the reviewers of this manuscript for their thoughtful and comprehensive comments, which helped us clarify our views and significantly strengthened the manuscript.

Appendix A: Investigator checklist for proposing social media recruitment

Investigators proposing to recruit via social media are advised to take the following steps:

A list of the sites to be used.
A description of whether recruitment will be passive and/or active.
If utilizing active recruitment, a description of how potential participants will be identified and approached, and their privacy maintained.
Ensure that the social media recruitment strategy complies with applicable federal and state laws.
Seek an exception from the website to its terms of use; provide the IRB with written documentation of the exception, if granted.
Depending on IRB policy, in compelling circumstances make the case that the recruitment strategy should be allowed to proceed in the absence of an exception from the site.
Proposed recruitment does not involve deception or fabrication of online identities.
Trials are accurately represented in recruitment overtures.
Proposed recruitment does not involve members of research team ‘lurking’ or ‘creeping’ social media sites in ways members are unaware of.
Recruitment will not involve advancements or contact that could embarrass or stigmatize potential participants.
Provide the IRB with a statement explaining this approach and describing plans to obtain consent and documentation of consent from participants before approaching members of their online networks or to invite the individual themselves to approach members of their network on the research team’s behalf.
Steps to educate participants about the importance of blinding and how certain communications can jeopardize the scientific validity of a study (e.g., a section in the orientation or consent form)
Triggers for intervention from the research team (e.g., misinformation or speculation among participants on social media that could lead to un-blinding)
Interventions from the research team (e.g., corrections of misinformation or reminders about importance of blinding on social media)

Appendix B: IRB checklist for evaluating social media recruitment proposals

IRBs evaluating protocols that propose to recruit via social media should take the following steps:

Seek to normalize social media recruitment to the extent possible, drawing analogies to traditional recruitment efforts.
Ensure that the proposed online recruitment strategy complies with all applicable federal and state laws.
If a proposed technique conflicts with website policies and terms of use, request that the investigator seek a written exception from the site, OR
Depending on IRB policy, request a written statement from the investigator explaining why the recruitment strategy warrants approval without an explicit exception, to be evaluated by the IRB with input from institutional legal counsel.
Proposed recruitment does not involve deception or fabrication of online identities
Trials are accurately represented in recruitment overtures
Proposed recruitment does not involve members of research team ‘lurking’ on social media sites in ways members are unaware of
Recruitment will not involve advancements or contact that could embarrass or stigmatize potential participants
Ensure that investigators will obtain consent from current participants before they approach members of their online network for recruitment via their network or invite individuals to approach members of their network on research team’s behalf.
Ensure that a communication plan is in place for how the research team will handle online communication from enrolled participants that threatens the integrity of study.

2 While the Secretary’s Advisory Committee on Human Research Protections, a federal advisory committee of the Department of Health and Human Services, has issued non-binding recommendations on internet research generally ( SACHRP 2013 ), those recommendations do not cover recruitment to research or clinical trials specifically in sufficient detail to yield actionable advice on many important issues that concern us here.

3 Online searches revealed the existence of IRB policies or guidance documents addressing social media recruitment from the University of Pennsylvania, Cornell University, Indiana University, Johns Hopkins School of Medicine, Purdue University, Quorum Review, and The Feinstein Institute for Medical Research (see Works Cited for references and links). There is wide variation among these documents over the topics covered as well as the degree of analysis provided.

4 The guidance document is “The Use of Social Media in Recruitment to Research: A Guide for Investigators and IRBs.” https://catalyst.harvard.edu/pdf/regulatory/Social_Media_Guidance.pdf .

5 The federal regulations do permit research involving deception under certain conditions, but even in these situations the value of the research should be weighed against the possible deleterious effects on public trust and whether the research can be done using other, non-deceptive methods.

6 We acknowledge that researchers have good reason to familiarize themselves with the privacy policy and terms of use of social media platforms, both to evaluate whether the proposed research coheres with a site’s terms of service (see below, Section 4.1) as well as to ensure that the site will not use the data it collects from tracking responses to recruitment ads in ways that violate the Belmont principles. If there is evidence of particular social media platforms failing to respect the rights of its users or acting with blatant disregard for their interests, investigators have strong ethical reasons to avoid using those sites for research purposes.

7 Respect for the stated terms of use of the site is, however, within the purview of the institution or sponsor of the research, as discussed below.

8 Such as those developed by the Center for Information and Study on Clinical Research Participation, here: https://www.ciscrp.org/primer/ . See also McNair.

Contributor Information

Luke Gelinas, Petrie-Flom Center at Harvard Law School and Harvard Catalyst.

Robin Pierce, Petrie-Flom Center at Harvard Law School and Harvard Catalyst.

Sabune Winkler, Harvard Catalyst.

I. Glenn Cohen, Petrie-Flom Center at Harvard Law School and Harvard Catalyst.

Holly Fernandez Lynch, Petrie-Flom Center at Harvard Law School, Harvard Catalyst, and Center for Bioethics, Harvard Medical School.

Barbara E. Bierer, Brigham and Women’s Hospital, Harvard Medical School, and Harvard Catalyst.

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Open access
Published: 01 April 2024

Paramedic attitudes and experiences working as a community paramedic: a qualitative survey

Aarani Paramalingam 1 ,
Andrea Ziesmann 1 ,
Melissa Pirrie 1 ,
Francine Marzanek 1 ,
Ricardo Angeles 1 &
Gina Agarwal 1 , 2

BMC Emergency Medicine volume 24 , Article number: 50 ( 2024 ) Cite this article

Metrics details

Community paramedicine (CP) is an extension of the traditional paramedic role, where paramedics provide non-acute care to patients in non-emergent conditions. Due to its success in reducing burden on hospital systems and improving patient outcomes, this type of paramedic role is being increasingly implemented within communities and health systems across Ontario. Previous literature has focused on the patient experience with CP programs, but there is lack of research on the paramedic perspective in this role. This paper aims to understand the perspectives and experiences, both positive and negative, of paramedics working in a CP program towards the community paramedic role.

An online survey was distributed through multiple communication channels (e.g. professional organizations, paramedic services, social media) and convenience sampling was used. Five open-ended questions asked paramedics about their perceptions and experiences with the CP role; the survey also collected demographic data. While the full survey was open to all paramedics, only those who had experience in a CP role were included in the current study. The data was qualitatively analyzed using a comparative thematic analysis.

Data was collected from 79 respondents who had worked in a CP program. Three overarching themes, with multiple sub-themes, were identified. The first theme was that CP programs fill important gaps in the healthcare system. The second was that they provide paramedics with an opportunity for lateral career movement in a role where they can have deeper patient connections. The third was that CP has created a paradigm shift within paramedicine, extending the traditional scope of the practice. While paramedics largely reported positive experiences, there were some negative perceptions regarding the slower pace of work and the “soft skills” required in the role that vary from the traditional paramedic identity.

Conclusions

CP programs utilize paramedic skills to fill a gap in the healthcare system, can improve paramedic mental health, and also provide a new pathway for paramedic careers. As a new role, there are some challenges that CP program planners should take into consideration, such as additional training needs and the varying perceptions of CP.

Peer Review reports

Community paramedicine (CP) is an emerging professional role where paramedics use their training and skills in emergency response to respond to individuals with non-acute needs who do not require transport to hospital [ 1 ]. In Ontario, Canada, CP programs have begun to garner attention as an innovative approach to support independent living in an aging older adult population with complex health conditions [ 2 ]. Although there were some very early adopters of CP programs in Ontario, these programs began to gain momentum in 2013 [ 3 ]. By 2014, 13 Paramedic Services in Ontario reported having CP programs [ 2 ]. Community paramedicine programs can be diverse in scope, and can include paramedics completing home visits to frequent 911 callers, supporting clients with healthcare navigation, providing community-based education, and conducting drop-in clinic style wellness programs [ 1 ]. The structure, mandate, and resources required for CP programs tend to vary by paramedic service and local contexts. Staffing and training arrangements can also vary, with some programs designating full-time ‘community paramedics’ while others deploy paramedics on modified duties to staff programs.

Our literature review found that few studies have sought to understand how paramedics experience and view these programs. Evaluations of CP tend to focus on patient experiences, such as their health outcomes and health service utilization [ 4 , 5 , 6 ]. While participants have generally expressed support for and acceptance of CP [ 5 , 6 ], it is unclear exactly how paramedics perceive CP programs, particularly as it relates to their understanding of paramedic professional identity and their mental health.

As the CP role becomes a more permanent part of paramedic practice, it is expected to redefine and broaden the paramedic identity beyond its traditional boundaries. Historically, service users and healthcare providers have defined paramedics as thrill seekers who provide transport, emergency response, and trauma care [ 7 ]. However, as the delivery of healthcare has become more complex and integrated, paramedic identity has also shifted. Paramedics in Canada have already adopted broad professional identities such as ‘clinician,’ ‘educator,’ ‘team member,’ and ‘patient advocate’ [ 8 ]. This expansion of the paramedic identity is expected to accelerate as CP programs are increasingly adopted in Ontario. CP programs require paramedics to work with individuals on a repeat basis, provide chronic disease management services, and use ‘soft’ skills such as motivational interviewing and advocacy. How paramedics feel about these changes to their professional identity as a result of CP has yet to be understood.

Additionally, participation in the CP role may alter paramedics’ mental health experience. Paramedics in traditional emergency response roles tend to experience Occupational Stress Injury (OSI) due to demanding work environments and exposure to traumatic incidents [ 9 , 10 ]. Occupational Stress Injury refers to any form of psychological stress resulting from the duties one performs on the job [ 9 ]. While OSI is common for all public safety personnel, some studies suggest a higher incidence of post traumatic stress disorder for paramedics when compared to police officers and firefighters [ 11 , 12 ]. Paramedics are estimated to be at higher risk of screening positive for a DSM-IV mental disorder than municipal or provincial police services, firefighters, and dispatchers [ 12 ]. While some preliminary research in one CP program suggests that paramedics who practice CP experience reduced stress and a greater quality of work life [ 9 ], it is unclear how working in CP programs in different capacities may alter paramedics’ exposure to OSI and affect one’s overall mental health.

This paper seeks to describe the positive and negative experiences of paramedics working in a CP program and assess CP’s impacts on paramedic professional identity and paramedic’s mental health experience. As paramedic experiences may not be aligned with the experiences of CP program participants or even paramedic leadership, this paper also seeks to identify workplace elements (e.g., training, supports, paramedic leadership and culture) that may promote or hinder the expansion of CP programs in Ontario.

A survey tool was developed and distributed by the McMaster Community Paramedicine Research Team in 2016, using the online platform FluidSurveys, to assess paramedics’ perceptions and experiences working in a CP role. The survey was developed based on recurring themes and insights from a focus group and three key informant interviews with paramedics. The survey drafts were also reviewed and approved by a paramedic and a paramedic superintendent with research experience. The survey tool used open-ended questions to have paramedics describe their perception of the CP role prior to, and after working in a CP program, including both positive and negative aspects.

Population and recruitment

Paramedics were invited to participate in a survey that was distributed through social media by the Ontario Paramedic Association and the CP@clinic program. On Twitter, the invitation to complete the survey was re-tweeted by multiple accounts including paramedic services, paramedic staff, and other accounts. In addition, some Paramedic Services in Ontario delivering CP programs emailed the survey link to their paramedic staff. All paramedics (with and without CP experience) were invited to complete the full survey, but only those who indicated that they had worked in a CP role were included in this study (screening question in the survey). Respondents were informed about the purpose of the research study and informed consent was obtained. This study was approved by the Hamilton Integrated Research Ethics Board (Project #13-466).

Data collection

A convenience sample was collected using an online survey. The survey was available for 16 weeks from October 2016 to January 2017, to provide ample time to gather responses from all potential participants. Data from the open-ended questions were collated into a single transcript.

The survey collected the following demographic information: age, sex, years of service, type of paramedic training (i.e., primary care, advanced care, critical care), whether the paramedic was on modified duty while working in a CP program (i.e., awaiting return to regular duties), length of time working in CP programs, and types of programs they worked in. Fivetypes of CP programs were provided as options: home visit program, clinic style program, paramedic navigator style program, triage program, and other.

The following open-ended questions were asked to elicit responses about paramedics’ experience of the CP role:

What was your opinion of community paramedicine before working a community paramedicine role?

Please explain how your opinion of community paramedicine has changed since working in a community paramedic role?

What was positive about your experience working in a community paramedic role? What did you enjoy about this role?

What were the negative aspects in your experience working as a community paramedic?

Would you like to change anything about the community paramedic role?

A comparative thematic analysis was used to describe the experiences of community paramedics before and after working in a CP role. Two members of the research team (AP, AZ) independently coded responses and identified emergent themes. Using a phenomenological approach during secondary coding, coders grounded the emergent themes within paramedics’ lived experience of the community paramedicine role, finding explanations for their experience within the context of the data itself. Responses with thick narrative descriptions were retained for analysis. Incomplete or partial responses were included in the qualitative analysis. Themes were then synthesized, refined, and were validated and triangulated by research team members (GA, AZ, MP, FM, RA). The demographic data was analyzed using descriptive analysis.

Demographics

Of the total survey respondents ( n =434), 79 reported working in a CP role. These respondents were predominantly male (57.0%), had 10 or more years of experience in a paramedic role (77.2%), and were not on modified duty while working in a CP role (86.1%). Respondents reported experience with working in multiple types of CP programs, with the most common type being clinic style programs (68.4%) (see Table 1 ). While the survey was open to all paramedics, the majority of respondents report working in Ontario ( n =61, 77.2%) and 16 respondents (20.3%) did not provide the province in which they worked.

A number of themes and sub-themes emerged from the analysis. Before having worked in a CP program, paramedics broadly identified three unique opportunities and impacts of the CP role: 1) filling gaps in emergency response and the healthcare system at large, 2) providing opportunity for lateral career movement, and 3) creating practice paradigm shifts. After working in a CP role, respondents were able to describe in detail the positive and negative aspects of these three opportunities and impacts. These themes are conceptualized in Fig. 1 .

Diagram depicting the major themes and the positive and negative experiences of paramedics working in a CP role

Theme 1: CP programs can fill important gaps in emergency response and the healthcare system at large, but come with new professional challenges

Before working in a CP role, the majority of respondents viewed the CP role positively. CP was thought to fill important gaps in emergency response and the health system at large. It offered paramedics an opportunity to practice continuity of care by providing prevention and disease management support to older adults who were often inappropriately accessing emergency care services. Paramedics felt that the needs of these individuals were not being fulfilled through traditional emergency response.

There are several individuals I have come across in my career who would have benefitted from a regularly scheduled home visit. ...There are a lot of individuals who require that [health] maintenance… it greatly reduces the workload of Emergency Services and frees them up for what they are actually required for – emergencies. (P.24)

[I thought] it was a vital service that filled gaps in the health care sector that was having excellent results where implemented (P.43)

After working in a CP program, respondents expanded on these initial sentiments. They described delivering a different level of care to their communities that involved stepping into a novel helping role, building relationships with participants and their families, supporting participant health outcomes, and taking part in interprofessional collaboration. This new level of care also came with new professional challenges such as increased emotional burden, managing participant expectations, and conflicts with other health and social service providers.

Sub-theme 1A: being in a helping role

Helping program participants in a CP role was described as novel and different when compared to the emergency response role. Community paramedics worked with participants on a long-term basis and witnessed their health and quality of life improvements. Paramedics enjoyed helping participants who were part of vulnerable or underserved communities. By taking time to listen to these participants and hear their stories, paramedics were able to exercise more compassion and felt less judgemental about participants’ situations. This was a rewarding aspect of the CP role, even having a powerful positive effect on paramedics’ own mental health.

Making a difference in people's lives ... often the people in the community who are ignored and shunned by others. I enjoyed going out in the community, solving problems, working with other services, having the time to LISTEN to patients rather than be worried about my scene time...this is one of the most important things for Paramedic mental health as well. (P.46)

...the knowledge that community paramedics, with sometimes very simple interventions/strategies can make all the difference in people's lives, preventing people from falling through the cracks, or helping them out of that situation…(P.61)

Sub-theme 1B: relationship building with program participants

Paramedics enjoyed building relationships with participants and getting to know them on a personal level, which was not possible in an emergency response role due to limited time on scene during acute calls. Building rapport with participants in the comfort of their homes created a sense of trust that fostered into natural friendships, with some paramedics describing themselves as building a ‘family’ with participants. Others noted that this trust allowed participants to share more details about their health and medical history, allowing paramedics to better assist in their care. Paramedics felt it was important to build these strong social relationships with participants in order to encourage and affect health behaviour changes for participants. Strong relationships with participants allow paramedics to thoroughly follow-up after initial visits and engage in conversations about participants’ short- and long-term health goals. Additionally, although the CP role lacked the adrenaline rush, this increased socialization was described as filling this gap.

The paramedics have built a rapport with [participants] and have really built a family with them.(P.19)

Getting to know [participants] beyond the 30 minutes to an hour we’re used to being with [them in an emergency capacity]. I found as they got to know me, they were more willing to share health concerns they were having and trusted me more. (P.26)

I realized that community paramedicine can be more enjoyable than I thought…where it lacks in adrenaline it makes up for in a social aspect. (P.10)

Seeing how much they trust us and tell us some of their most intimate issues. (P.49)

Sub-theme 1C: emotional burden

While paramedics enjoyed the rapport and relationships built with participants, they also felt they were making greater emotional investments in participants who were in poor health, may have been in a palliative state or dealing with addictions issues. Burnout, attachment fatigue, and difficulty dealing with participant deaths were common experiences. For some paramedics, having built rapport with certain participants meant that they were the primary contact for follow-up care even on their days off, leading to poor work-life balance. Similar to other clinical practitioners who work one-on-one with individuals over a long period of time (e.g., physicians, social workers), one respondent emphasized the need for paramedics in a CP role to be trained to reflect on their experience and make adjustments to how they work with participants.

Can be emotionally draining working over the long term with [participants]... who are very sick, some are palliative, difficult personalities, addictions, etc. Paramedics historically aren’t used to becoming emotionally involved with [people] … but this is difficult not to do when you are seeing people over and over again, and getting involved with their families and other circles of care as well. (P.5)

Couldn't just leave work behind at work like a traditional paramedic could - had to field phone calls on my vacation to help make arrangements for a [participant]... because no other community paramedics were available or as familiar with [them]. (P. 9)

Paramedics are not usually trained, educated, or encouraged to engage in self-reflective or reflective practice and it’s essential for a role like community paramedicine. (P. 34)

Sub-theme 1D: participant outcomes

Paramedics reported a better understanding of the impact of CP programing on participants’ health and well-being. Identifying ‘silent’ health issues before they resulted in emergency transport, making appropriate referrals and reducing 911 calls were some of the positive outcomes. For some, their CP training had become an integral part of their role as a paramedic overall, providing valuable transferable skills that could also be used during an emergency response to further improve health outcomes and close gaps in care. Additionally, beyond identifying health issues and making appropriate referrals, some paramedics felt that CP programs help build a sense of community, which may in turn also improve participant health and well-being. Paramedics particularly appreciated being able to witness these positive outcomes first-hand.

I have realized that community paramedicine has a very broad impact in the community. It is very underappreciated ... It has improved the livelihood of many [participants], and can (with the aid of other resources), assist them [with] their healthcare needs. (P.9)

Seeing them get proper treatment for an illness they did not know they had (i.e. hypertension, diabetes). (P.62)

Seeing the direct benefit of timely and appropriate interventions; having a big impact on people's quality of life, even when palliative (P. 60)

I see that most [people] don't want to go to the hospital and really don't need to. The issue is [that in] our current system people expect to be taken as they think that's the only way a doctor will see them. When they realised someone could see them at home and then refer them to the required service less 911 calls were made. (P.10)

I'm fortunate enough to work in a service that has integrated some aspects of community paramedicine into every response. Being trained to recognize signs in a [participant]'s home that indicate a higher need for home care and offering ways for them to access more care is deeply satisfying. The relief on a person's face when told they could get some home care, or help with day to day chores makes me feel like I made a difference to their quality of life. (P.36)

Seeing how much change we were able to create in a short period of time. Watching the sense of community flourish in the buildings while we were there. (P.49)

Sub-theme 1E: managing participant expectations

Managing the expectations of program participants and trying to elicit health behaviour change was a challenging aspect of the CP role. While seeing positive improvements in participants' lives motivated community paramedics and likely provided them with increased job satisfaction, working with participants who were not able to achieve these positive outcomes in some participants despite working to identify their health issues, and referring and connecting them to services, was a frustrating aspect of the role. Paramedics experienced frustration when participants did not follow their health advice, did not experience improvements in their health, or when participants expressed dissatisfaction with the help they received. Some of this frustration was also directed towards referral agencies who were not able to help the participant.

Some people are noncompliant with their medications or taking the advice of their physicians. It can be frustrating having people come to you for help for the same problems but not be receptive to the advice that you give. (P. 42)

There have been moments of frustration when patients don't follow through or even attempt to follow advice given to them by myself or the agency that has been tasked with giving them assistance. (P. 42)

[Some] clients who are out of the normal scope of practice for a paramedic who are better served by other agencies but those agencies failing the client. Even when you help put services in place for a client they are not happy and want more. (P.7)

Sub-theme 1F: interprofessional collaboration

Paramedics enjoyed working with differenthealthcare providers in their community. Collaboration with different services and providers was felt by paramedics to benefit program participants and improve their career satisfaction. Collaboration with different healthcare providers outside of an emergency paramedicine context made paramedics feel respected and part of a valued healthcare team that was centred around improving participant health. This collaboration provided better coordinated care and also showcased paramedics’ clinical skills beyond that of transport and ambulance-driving to other healthcare professions.

The integration, collaboration, and cooperation with health care and with allied health care providers. We truly make a difference in people's lives, keeping them in their homes longer, safer, and healthier. (P. 67)

Building relationships and pathways with community health care providers and showing them that paramedics are more than just ambulance drivers. (P. 13)

Interacting with the [primary care provider] as we caught early onset [urinary tract infections (UTIs)] and [upper respiratory tract infections] with treatment started based solely on our assessment and conversation via cell phone with [the provider] saving [the participant] stress and cost of travelling to their office. (P. 49)

...Enjoy working more closely with physicians to develop treatment plans.(P.56)

Sub-theme 1G: conflicts with other service providers

While paramedics appreciated the interprofessional collaboration offered by the CP role, they also described conflicts and challenges working with other service providers in the health and social work sector. Paramedics described some service providers as failing and unable to meet participant needs. Overlap between CP activities and other healthcare roles also led to tensions regarding professional boundaries, including physician concerns about CPs diagnosing their patients.

Some doctors did not like paramedics assessing and diagnosing issues (e.g. chest infections, UTIs, and muscular-skeletal injuries). (P. 39)

Don't know if referrals are getting back to [participants]…[There are] already programs in place that have [the] same mandate as CP, like Health Link, forcing medics to do home visits when [participants] don’t need them any more. (P. 12)

Oftentimes, navigating the system was a challenge and often wait times with family doctors or other services were unavoidable. (P. 29)

Theme 2: CP offers paramedics an opportunity for lateral career movement that is free from the demands of shift work and allows them to be connected to the community in a clinical capacity that is slower paced.

Some respondents viewed CP as a new opportunity for lateral career movement within the paramedic profession, ideal for paramedics in the late-stage of their career as it offered less physically demanding work. It was also noted that CP could help keep aging paramedics in the service for a longer period of time and the community could continue benefiting from their skill set.

After having worked in the new role, paramedics described CP as offering greater freedoms compared to the demands of shift work in traditional emergency response roles. CP offered freedom from the demands of shift work by providing better hours, increased autonomy, reduced physical demands, and reduced paramedic stress. For paramedics with longer years of service, this was a welcomed change of pace, with some reporting mental and physical health improvements. Others noted the importance of still being connected to the community in this new role. For others, adjustment to the slower pace of the CP role was difficult due to their preference for emergency work..

I enjoyed being still involved with the community but not having to have the daily physical demands of responding to 911 calls. The role is less stressful and after being a paramedic on the road for 14 years it is an amazing and a welcome change of pace both mentally and physically. (P. 58)

The autonomy to structure my day without the oversight of dispatch or supervisors. (P.63)

[It] would be great for light duty/modified work, could keep aging medics on for [a] longer period of time, good idea for last years of work. (P.51)

I prefer a higher paced environment dealing with acute injuries…(P.30)

Theme 3: Paramedics viewed and experienced the CP role as a practice paradigm shift

Before working in a CP role, paramedics viewed ed CP to be a practice paradigm shift for the profession. For some, this shift in practice was thought to be in opposition to the traditional emergency care role while others felt it was a natural extension of paramedic practice.

I did not feel that was something I would enjoy as it does not have the same adrenaline rush you get when on emergency calls. (P. 13)

[I] felt it was long overdue and a natural extension of what we were already doing in an emergency capacity. (P. 43)

I thought that it would be the next step in emergency medicine, our next frontier. Fire has prevention, we should have health promotion. (P. 26)

After working in a CP role and experiencing the practice paradigm shift first-hand, paramedics noted being largely satisfied by their newly expanded skill set, but also felt that it was a significant learning curve. Paramedics experienced negative sentiments from their peers in traditional emergency response regarding the CP role, highlighting the diverging paradigms between the two roles.

Sub-theme 3A: expanded skill set

The CP program expanded paramedics’ skill set to provide better care to program participants. Some of the new clinical skills described included medication provision, suturing, catheterization, point-of-care testing. Paramedics felt these skills improved their overall ability to perform when returning to emergency response duties. Others felt these new clinical skills were not used or required for the CP role because participants were mainly looking to socialize and interact.

I very much enjoyed the increased scope of practice. I believe that it allows me to provide better care and assist people in the community more than I have before. Moreover, I feel that the additional training has made me a better, and more well-rounded medic overall. (P.34)

I enjoyed the expanded roles (phlebotomy, catheterization, suturing etc)...(P.25).

Sub-theme 3B: learning curve

Working in a CP role was a significant learning curve for some paramedics. Challenges included learning soft skills such as communication, confidence leading sessions with older adults, and learning administrative tasks such as new documentation and computer skills. For paramedics working in both emergency response and CP roles, it was difficult to shift between emergency response protocols and CP protocols. This may have been due to competing priorities between emergency response and CP protocols, such as deciding whether to transport an individual to hospital or keeping an individual at home.

It is a difficult shift in frame of mind to go from 911 assessments to CP assessments and having to switch back into 911 mode when necessary...It can be tough to play the role of both emerg[ency] response and CP. (P.18)

Adapting to new ways, changing the way you do calls, learning the CP documentation and computer programs, being confident with [program participants] and visits, knowing when to communicate with the providers and how. (P. 2)

Much more patient advocacy & health teaching then I had expected. (P.14)

Sub-theme 3C: negative paramedic culture

Community paramedics described a negative paramedic culture that is unaccepting of the CP role and its softer skill set. Lack of buy-in from paramedics in traditional emergency response roles, along with poor understanding of the positive impacts of CP programming, have led to negative perceptions of the role in the paramedic workforce. Community paramedics felt that their emergency response colleagues did not respect their role and felt misunderstood by the profession at large.

Paramedic culture that needs to be educated and changed on the value of CP work. (P.32)

Misunderstood by co-workers and some management. Labeled the tea and cookie brigade. (P.24)

I also found that EMS crews treated CP with very little mutual respect and understanding... (P. 41)

There were a number of positive and negative aspects of the CP role identified by paramedic respondents. While the majority of respondents felt that working in a CP program was a largely positive experience, some expressed dissatisfaction and difficulty adapting to the role. Many positive aspects of the CP role also had unintended negative aspects, particularly as it related to paramedics’ sense of professional identity and their mental health experience when working in the CP role. In order to ensure paramedic job satisfaction and understand the future state of CP programs, these opposing experiences need to be further examined and addressed.

Paramedic professional identity

While many paramedics felt CP was an extension of the paramedic identity, some felt it was a threat to the traditional paramedic identity, removing the defining element of ‘emergency response’ and blurring professional boundaries with other health and social service roles. These diverging experiences and attitudes towards the CP role and its place in the paramedicine profession suggest that there are different fractional identities within the paramedic workforce. Donelley et al. found that emergency service workers often define their role using four domains: caregiving (helping individuals in need), thrill seeking (the adrenaline rush experienced during critical incidents), capacity (having the knowledge, skills, and training to act), and duty (obligation to one’s community and service) [ 7 ]. Paramedics who understand their professional identity as falling within the ‘caregiving’ or ‘duty’ domain may be more accepting of the CP role and understand its fit within their existing paramedic mandates. However, paramedics who understand their professional identity as falling within the ‘thrill seeking’ and ‘capacity to conduct an emergency response’ domain may view CP as not only redefining and expanding the profession, but a threat to the professional identity. Expansion and further resourcing of CP programs may exacerbate divisions and tensions between staff who have different professional motivations if these concerns are not addressed.

Paramedic mental health

Working in a CP role may have also led to some improvements in paramedic mental health. In the traditional emergency response role, paramedics take on shift work, are often exposed to traumatic emergency response incidents, and are limited in their interactions with individuals in their care (single touchpoint and limited time). In contrast, community paramedics experienced more freedom to structure their day, new opportunities to build relationships with program participants due to multiple touchpoints and they experienced reduced physical demands. These experiences likely contributed to a less stressful, flexible work environment which in turn improved mental health for some.

However, increased socialization with participants also introduced new emotional burdens and stressors for some community paramedics. Increased attachment to program participants often made it difficult to deal with their deaths. Participants are often vulnerable populations who face complex health and social issues, such as poverty and addiction. Increased contact with vulnerable populations may increase paramedics’ exposure to vicarious trauma or ‘compassion fatigue,’ which refers to the secondary trauma experienced by working closely with individuals who have experienced trauma first-hand [ 13 , 14 , 15 ]. Vicarious trauma and compassion fatigue can have similar negative impacts on paramedic mental health as first-hand trauma, leading to emotional disturbances, stress, intrusive thoughts, and reduced productivity [ 15 ]. Particularly for community paramedics with a strong orientation towards empathy and caregiving, compassion fatigue may be experienced as a negative or challenging consequence of the role [ 15 ].

Considerations for CP programming

The experiences of paramedics working in a CP program suggests the CP role comes with new opportunities and challenges for staff and the profession at large. Paramedics have broad and diverse understandings of their professional identity, leading some to view CP as a natural fit within the profession while others view it as extending too far beyond the boundaries of paramedicine. This suggests the need for paramedic leaders to clearly define the purpose, mandate, and function of the CP role within the paramedic workforce. Paramedic services interested in implementing and expanding on CP programs to achieve program outcomes such as a reduction in emergency calls and improving participant health outcomes should reflect on their workplace culture and consider the role of their leadership in promoting this role. Champions of CP programming may be identified to better support the workforce’s understanding of this role and how it fits within larger paramedic mandates and objectives. Paramedic leaders who are championing the CP role should consider what factors may contribute to a paramedic feeling alienated in a CP role and how staff are selected to fill this role. In addition, negative perceptions of the CP role as ‘soft’ or ‘easy’ in comparison to emergency response roles needs to be dispelled if community paramedics are to feel valued for their efforts and contributions.

In addition, a number of training supports may need to be provided that take into consideration the new emotional burdens of the CP role. While the CP role may contribute to good mental health by providing a flexible work environment, reducing exposure to traumatic incidents, and allowing paramedics to socialize with individuals in their care, it may also put some paramedics at risk for vicarious trauma and compassion fatigue. Drawing from professions such as social work and counselling, a number of training and professional development supports can be provided to reduce compassion fatigue. Examining compassion fatigue in community paramedics, Cornelius et al. suggests that paramedics should establish boundaries when working with program participants, ensuring that participants recognize the relationship between them and the paramedic is time limited [ 15 ]. Additionally, the caseload of community paramedics should be examined and managed by supervisors in terms of size and complexity of cases [ 15 ]. Other paramedic supports could include resiliency training, counselling services, and stress management workshops [ 15 ]. Training provided should match the type and scope of the CP program the paramedic is working in and their work environment.

Limitations

A limitation of this study is that it used an online survey with predefined open-ended questions to extract information on lived experience rather than a semi-structured interview. This approach prevented researchers from prompting paramedics on their responses and engaging in discussion to obtain a deeper description of their experiences. However, the survey approach allowed the research team to obtain responses from a large number of paramedics and collect responses from across Ontario. Another limitation is that due to the inherent nature of the survey link, it cannot be guaranteed that unique responses were captured. However, multiple entries from respondents are unlikely.

Future research should attempt to engage paramedics on the issues described in this paper and should consider how the relative impacts of working in different types of CP programs (e.g., clinic style programs, at home visits, etc.) may affect paramedic experiences. This approach may provide more detailed data to inform future CP training and program design.

This paper found paramedics who have worked in a CP role, reported that the role offered opportunities to fill a gap in the healthcare system, to move laterally within the paramedic profession, and to create a practice paradigm shift within the profession. Most described having positive perceptions of their professional identity after working as a CP, as they were able to fulfill stepping into a helping role to a greater extent. In contrast, some came out of the experience with negative perceptions. It is important for CP program planners to consider these diverse experiences when planning for the expansion of these programs. A workforce culture that views CP programming negatively and as potentially eroding the traditional paramedic identity may work to hinder the program’s ability to achieve positive outcomes such as a reduction in emergency calls and an improvement in participant health outcomes. Incorporating the CP role within larger paramedic mandates and objectives by paramedic leadership may support this work, as well as CP champions who clarify the role and impacts of CP to staff.

Availability of data and materials

The data that support the findings of this study are not publicly available due to them containing information that could compromise participant privacy. De-identified, limited data will be shared by the corresponding author upon reasonable request.

Abbreviations

Community Paramedicine

Occupational Stress Injury

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We would like to acknowledge the assistance of Brent McLeod and the OPA (Ontario Paramedic Association).

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Aarani Paramalingam, Andrea Ziesmann, Melissa Pirrie, Francine Marzanek, Ricardo Angeles & Gina Agarwal

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The study was conceived of by GA, RA, FM and AP, AZ, GA, RA, FM and MP analysed the data. AP drafted the article under the supervision of GA and all authors were involved in editing to produce a final draft. All authors read and approved the final manuscript.

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Paramalingam, A., Ziesmann, A., Pirrie, M. et al. Paramedic attitudes and experiences working as a community paramedic: a qualitative survey. BMC Emerg Med 24 , 50 (2024). https://doi.org/10.1186/s12873-024-00972-5

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