Dr. Aman Hussain from the Faculty of Kinesiology and Applied Health knows a thing or two about learning in stressful environments. In the past, he’s coached athletes, consulted for Canada’s Royal Winnipeg Ballet, and worked with medical professionals. Now he’s working in partnership with the Winnipeg Fire Paramedic Service, conducting a mixed-methods study aimed at understanding how firefighters and paramedics are responding to, and have been affected by, the current pandemic.

On this episode the research question is “how do we learn more effectively while working in a high-stress work environment?”

AMAN HUSSAIN: COVID has exacerbated current issues within the context of learning and professional development. Just like many of us, we’re all managing the different issues associated with COVID and work in managing work. I think it’s safe to say that as we’re living through COVID, we’re dealing with the accumulation of, you know, different stressors. And all of these things have the potential to take away or detract from our performance, regardless of the context that we’re in.

KENT DAVIES: That’s Dr. Aman Hussain, assistant professor in the department of Kinesiology and Applied Health. His research focuses on high-stress professions, from professional athletes to the performing arts and more recently, medical professionals. Hussain is interested in knowing how emergency responders perform and learn while working in a high stress environment. First Responders have always faced substantial work demands which often involve prolonged exposure to various physical and psychological stressors. The public expects them to be prepared to perform at their best ability, regardless of the circumstances. But what happens when they encounter the added stress, anxiety, and uncertainty of the pandemic.

AMAN HUSSAIN: These are human challenges. It’s challenging in the midst of a pandemic to communicate procedural changes with the best evidence, and this is one of these interesting things where social media played a role, media played a role. You’re looking at what’s occurring in different jurisdictions and those protocols and procedures applicable within this jurisdiction?

KENT DAVIES: Hussain is exploring how firefighters and paramedics perform, communicate, and learn during the COVID-19 pandemic; and what we can learn from their experiences.

AMAN HUSSAIN: So, if I can find out what is most appropriate or what is the best form of learning or what are the challenges or barriers faced by those workers in the context of the pandemic. Then I can share that with the leadership, with the people who make decisions on that. For that, for those frontline personnel.   

KENT DAVIES: On this episode the research question is “how do we learn more effectively while working in a high-stress work environment?”

From the University of Winnipeg Oral History Centre, you’re listening to Research Question- amplifying the impact of discovery of researchers of the University of Winnipeg.

If you’ve worked in a high risk, high stress field chances you may already know Dr. Aman Hassain. Hussain has been a regular presenter at medical and military conferences. He’s consulted for Canada’s Royal Winnipeg Ballet, coached athletes and worked with first responders. His research has been conducted across a variety of disciplines using an array of different methodological approaches. And while his research skill set has taken him across the world. He’s found himself back here, at home, at the institution where he first started his post-secondary education.

AMAN HUSSAIN: So, I’m actually a Winnipeger. Or rather, I should say Winnipeg is my hometown currently. I actually was born in Selkirk and raised in a place called Pine Falls. Both my parents were teachers in Sagkeeng First Nation, when I was around seven years old, both my parents got a job with Winnipeg one school division in Winnipeg, and we made the move and moved to a neighbourhood called Waverly Heights. Elementary School, Junior High School in Waverly Heights. Afterwards, I attended Vincent Massey High School. I was accepted actually to the University of Winnipeg’s combined BA-BEd Integrated Program. So, I did my first two years at the University of Winnipeg, and I found that it was not for me. I was a less than stellar student, and it wasn’t because I didn’t enjoy education, it was just more I wasn’t mature enough and I wasn’t ready, I think, for the transition. The studying that you had to put in the follow through, you had to do with assignments.

KENT DAVIES: Hassain says at the time he was more interested in spending time on the slopes as a coach for the Manitoba Alpine Ski Division.

AMAN HUSSAIN: I was coaching. I was skiing. You know, it’s funny to be a Manitoba Alpine ski coach, but a lot of my time was actually spent in a place called Asessippi. I did a lot of work driving back and forth to Alberta, B.C., northwestern states, and doing a lot of the what’s known as the FIS or Nor-Am circuit for different ski races around there.

KENT DAVIES: Then in his third year at the University of Winnipeg, Hussain found classes that complimented to his passion for coaching.

AMAN HUSSAIN: I was very much drawn to some foundational undergraduate classes with two really wonderful profs here at the University of Winnipeg. Cal Botterill and Tom Patrick, and they both taught sport psychology, psychological skills in sport and life and leadership in sport. I was looking at how those really experienced coaches leveraged their knowledge and transitioned and passed along that knowledge to their athletes. And I was sort of struck by just really good coaches could simplify really complicated information into bite sized, digestible chunks to their athletes and man, that struck me. I was observing that at that time, and for me, it was those. It was those classes in my third year at the University of Winnipeg, where I was like, wow, I can learn more about this and I can leverage this into sport.

KENT DAVIES: After a meeting with Dr. Tom Patrick, Hussain was encouraged to further his education.

AMAN HUSSAIN: This was a prof who gave me the time of day and encouraged me to pursue further education. He encouraged me to go to grad school to if I wanted to do this professionally, if I wanted to make a career of this. And so that’s what I did. And I ended up doing graduate school at University of Ottawa focused on adult learning in the context of high-performance sport.

KENT DAVIES: While at the University of Ottawa, Hussain was introduced to a diverse range of approaches to research.

AMAN HUSSAIN: Some were studying sport psychology. Some were studying motor learning. Some were studying health psychology and promotion and adherence with different clinical populations. You know, I was just sort of really inspired by the different types of research occurring there. And I had tremendous mentors who were really wonderful and guided me for learning in what I now call NUTS professions.

KENT DAVIES: What is NUTS exactly?

AMAN HUSSAIN: NUTS is an acronym that stands for novelty, unpredictability, threat to ego and sense of control. And those are the sort of key characteristics that I currently study.

KENT DAVIES: These are the most common stressors according to Dr. Sonia Lupien, the director of the Centre for Studies of Human Stress.[i] So, if you break it down. N is for Novelty or learning something new, U stands for unpredictability; when things occur unexpectedly, T is a threat to the ego; feeling your competence is questioned, and S is for sense of control; feeling you have little or no control of a situation. All of these stressors are common in high-performance professions and Hussain was interested in learning how individuals can learn and improve their performance in these NUTS environments.   

AMAN HUSSAIN: But it started in sport. It started in high-performance coaching. You know, I wanted to learn more about how to enhance performance in a variety of different contexts. I was inspired by, you know, the learning that can occur, you know, with professional development in winter sports and this is being exposed to things like own the podium, road to excellence. And these were like national programs that supported national team programming and High-Performance coaching in Canada. And, I was really drawn towards that. You know, when I made the move back to Winnipeg, there’s not many national team programs that are actually here in Winnipeg.

KENT DAVIES: With the scarcity of national team sport programs based in Winnipeg, Hussain started looking for other NUTS professionals he could work with.

AMAN HUSSAIN: There are a variety of different programs that are high-performance and that very first program that dealt with sports psychology was, you know, some work with Canada’s Royal Winnipeg Ballet. I started doing work with them in terms of a consulting role with the resident program and the company program with the RWB. And the pivot was very easy to start working within the context of performing arts. Through performing arts. I was exposed to what’s known as an integrated sports science team. And this is where a group of professionals, you know, led by a physician, but working with a sports psych, that was me, nutritionist, massage therapist, physiotherapist, working collectively together to enhance the performance of the performers, the artists that we were working with. And again, this integrated interdisciplinary focus was again really fascinating to me I really liked… and could see, even at that time that that. Performance is not just one particular discipline or domain. It’s actually the balance and proper application of all of these collectively together that allow for really good performances to occur. And again, that was really fascinating to me and ended up being sort of sort of the transition into my doctoral work, which focused, you know, changed domains again, changed disciplines again, working towards emergency medicine.

KENT DAVIES: After attending a lecture given by Dr. Cal Botterill, Hussain changed his research focus once again, this time towards the context of emergency medicine.  

AMAN HUSSAIN: I was exposed to the challenges of emergency medicine and in specifically the challenges of learning how to become a physician. It was a random, grand rounds at the Health Science Center with the Department of Emergency Medicine, where my mentor, Cal had been asked to work with the department on I guess a small study on how a mental resiliency or mental skills program could actually be used for medical training. Interestingly, their instruments or measures used quantitatively didn’t find any significant differences, but the qualitative interviews afterwards showed tremendous, rich findings of how much the learners in that field valued the opportunity to share with one another the challenges that they were personally facing learning in this context. I was in the audience and very skilled resident at the time at the time stood up and said, Why can’t we have this? And that was the beginning of what’s known as the high performance physician program. I kind of made the connection of wow, something as simple as a basic psychological skills program for a group of residents, trainee physicians was so impactful. And for me, it was really kind of eye-opening because this is basic stuff. If you’ve ever taken a sport psych skills 101 sort of class, cognitive behavioral therapies, you know, goal setting, visualization imagery, arousal regulation, psyching yourself up, calming yourself down, positive self-talk, tactical breathing. These are basic skills that we teach children, young athletes and coaches, and it had not really been applied in the same context. It’s it was not really. And again, I was just in the audience, I was there to watch my colleague and my mentor. And that was the literal sort of stones at the top of the mountain that became a, you know, ever larger avalanche that really just directed me towards learning in the context of emergency medicine.

KENT DAVIES: There are parallels between athletes and medical practitioners. Both often rely on a team, face tremendous pressure, are heavily scrutinized, and will often face physical, mental and emotional exhaustion on the job. However, Hussain is quick to point out when it comes to NUTS workplaces, while the human challenges are similar – often the outcomes are not.

AMAN HUSSAIN: There are certainly different outcomes, you know, associated with the context, you know, fear of failure in the context of performing arts, you know, maybe you let down your parents or you let down the company or something like that, you know? Being cut, for example, like losing their position. But there’s a difference of fear of failure in that context, then fear of failure in the context of medical education or in the context of paramedicine or, public safety personnel, first responders, or even in the military where life and death situations can occur based on fear of failure or losing situational awareness for example, or decision fatigue or being frozen or choking, underperformance, given what you’re actually capable of based on the perceptions of the context or situation that you find yourself in. I learned a lot about applied sports psychology, not just the theoretical aspects but leveraging those theoretical and applied implications into the situation or context and population you’re working with. And so, for me, that was really, really foundational, and I took those foundational concepts, integrated them into my own practice as much as possible and then started applying them in the context that I was lucky enough to work in.

KENT DAVIES: For his doctorate Hussain wanted to study residents learning to become practicing attending physicians.

AMAN HUSSAIN: I was really just totally enamoured with the challenge of becoming a physician challenge of the overwhelming amount of work that was required as a resident. So, this is after med school, so this is after going through the rigmarole, the process of getting into a and being selected to a residency. There’s so much emphasis as there should be on learning the clinical aspects of anatomy, physiology, pharmacology, differential diagnoses, knowing what to do. Then there was some aspects that were algorithmic when you’re dealing with a closed airway. But throughout this process, there was never a focus on the human, the performer in that context. And so, this became, for me, a… man, if this hasn’t been studied, why not study it?

KENT DAVIES: And while his research study would be conducted with residents at the Health Sciences Centre here in Winnipeg, his thesis would ultimately lead him across the world to Brisbane, Australia, and the School of Human Movement Studies at the University of Queensland.

AMAN HUSSAIN: I was very lucky to work with Dr. Anthony Rossi or Tony Rossi at the University of Queensland. A tremendously impactful scholar. In between graduating my masters, I wanted to go to Australia to travel, but I also was interested in maybe looking at Australia as an option for doctoral work, and so I interviewed at a couple of different places. I went and spent time in their labs. And the relationship, the ease of interacting with Tony. The fact that he was not a physician and that we’re approaching this from an adult learning perspective really appealed to me. And we also had allies in the context of medicine. There were people who were like, yes, we should be studying this.

KENT DAVIES: For his doctoral study, Hussain embedded himself over the course of a year with a cohort of residents at the Health Sciences Centre in Winnipeg.[ii]

AMAN HUSSAIN: I borrow from an eclectic background of different methodologies and theoretical frameworks. I value spending time with my participants in their workplaces. And so, I borrow from an anthropological sociological perspective, you know, ethnographic embedding myself within the communities and participants that I am studying. And so, I ended up essentially following a cohort of residents in sort of a one-year time period. And this was junior residents to fifth year residents as they were learning throughout the different clinical rotations that they had to do. And at the same time, I was encouraged to connect with what I called early career mid-career and late career attending physicians. And so, they encouraged me to interact with them. And so, it actually just became through development of rapport. It was a group of about 12 residents. This was a great group of young people. They were my age. We were all interested in the same sort of stuff. I offered an outside perspective from a performance psych perspective. They were really excited to show their workplace, their context. And they really encouraged us to take part in observations. Follow me. See the challenges that I am faced with. And then let’s go for a coffee and let’s talk about it and debrief it. And what are your perceptions? What are your ideas on how to manage that? That’s where it came out of. What I ended up finding out was I saw this really kind of snapshot of learning from the perspective of residents. But then, there was almost this perception that as soon as you graduated residency, you don’t have to learn anymore. Like, I know everything. Don’t worry. And you know, the early career attending physicians were like, no, that’s where learning actually just starts. You know, like again, that transition from being a resident into clinical practice and, you know, in quotes, having that supervision, you know, where you’re actually responsible for everything like that wasn’t actually talked about, you know, unless it was informal.

KENT DAVIES: One main finding Hussain made during the course of his study is that learning emergency medicine during a residency is a balancing act that involves dynamic changes in the resident’s identity.[iii]

AMAN HUSSAIN: The nature of learning in residency is just a balance between service and autonomy service in the fact that you are a physician and you’re taking care of patients and autonomy in the sense that you know you’re learning how to make clinical decisions based on the information provided. You’re also balancing the responsibilities of the curriculum within residency. You’re learning from patients and mentors. So, mentorship is incredibly important.

KENT DAVIES: Hussain also observed that residents adopted new ways to communicate more efficiently through technology.

AMAN HUSSAIN: What was really kind of interesting at the time and which I actually just published on was the increasing, I’ll call it the increasing incorporation of technology into clinical practice, and I don’t mean technology like FMRIs or CT scans, but literally you know, cell phones. Applications on your cell phone, such that cell phones have been as ubiquitous as stethoscopes, you know, in today’s clinical workplace. But this has actually been brought in by the residents themselves. And so, you know, there are some really interesting implications associated with that.

KENT DAVIES: His study also reinforced the degree to which medical professionals rely on each other to do their job effectively.

AMAN HUSSAIN: Emergency medicine it is unpredictable but highly interdependent and interdependent means you require everyone to be on point to have the best outcomes for your patients. That’s the nursing staff, that’s the paramedics on the route to the E.R. That’s the janitorial services. That is the health care aids. That is the RTs, OTs, PTs. That’s the families, the social workers. It’s much more than just the residents.

KENT DAVIES: This recognition of interdependence amongst healthcare workers was made even more evident during one emergency room observation by Hussain.  

AMAN HUSSAIN: Through my doctoral work, I actually engaged in observations in the E.R. And it just so happened that one of the senior residents that I was observing was a former paramedic, a very well-respected paramedic who was what’s known as an advanced care paramedic, and he went from advanced care paramedic to med school and wanted to go into emergency medicine. And I was observing him at the time and a very, dramatic. instance where clinical decisions had to be made really quickly to ensure the best patient outcomes, and he was talking about this while paramedics were actually in the E.R. and he just offhanded a statement, that essentially was something like if you want a true understanding of this work context, it actually begins with them. And he gestured to a group of firefighters and paramedics that were in the E.R. and that always stuck with me.

KENT DAVIES: Following Hussain’s doctoral work, and tenure track designation he began to establish a research program from his previous experiences by expanding his research to include first responders.

AMAN HUSSAIN: My current work is actually focused, I would say, primarily on the ongoing learning and professional development in those NUTS workplaces. Specifically, I’m really interested in the informal learning that occurs in those areas. The light bulb for me was I could establish my research program focused on public safety personnel. And they were really just sort of interested. And it was through that process where I came to my current research mission, serve those who serve. So, engage in research that serves the populations. The police officers that I work with, the firefighters, that I work with, the paramedics that I work with. The work that I do ultimately serves them in some way.

KENT DAVIES: Hussain’s latest research study has him working in partnership with the Winnipeg Fire Paramedic Service. Over the course of the COVID-19 pandemic a lot of research has been published focusing on the occupational health and safety for health professionals. Like other health care professionals, paramedics have reported increased stress, exhaustion and anxiety caused by the pandemic has negatively impacted their mental health.[iv] But that’s not all. Numerous policy and protocol changes, increased demands along with the unpredictable nature of pandemic has also affected their ability to learn and perform. The study, titled Leveraging the Experiences of Firefighters and Paramedics’ in Winnipeg, MB: Lessons from the COVID-19 pandemic examines how firefighters and paramedics made decisions, communicated work-related information, and responded to challenges throughout the pandemic.[v] Through a survey and series of interviews with WFPS members, Hussain focused on how COVID-19 has impacted opportunities for learning and professional development.

AMAN HUSSAIN: The purpose was to look at and investigate the learning and professional development as it occurs in the midst of COVID. So, while COVID is occurring and broadly, the main finding is that COVID essentially exacerbated current issues with professional development and learning, you know, things like physical distancing and isolating, quarantining really disrupted that. Perhaps the best way of describing it is clear understandings on how to communicate effectively. I think it’s safe to say we all were overwhelmed with the amount of information and changes in procedure and what’s safe and what’s not safe and how many boosters are we supposed to get and what type of masks are we supposed to be wearing? And, you know, for firefighters and paramedics, it wasn’t just the masks. It was actively going out to potentially COVID positive patients. What are the procedures associated with cleaning and quarantining after you’ve transported a patient? And there were policies and procedures in place, but they needed to be updated or they needed to be communicated to the organization and frontline personnel effectively. And so there was just a broad learning that was occurring within the organization. A lot of people were really pleased with the amount of PPE availability and the participants that we spoke with were more concerned about transitioning to home. That was their main source of anxiety. It wasn’t work, it wasn’t being exposed to the patients. That wasn’t their main concern, it was actually endangering my spouse or my children transitioning from home. And so, more nuance then what we hear in the media I suppose. One thing I would say also, was even though my study was focused primarily on-going learning and professional development unprompted mental health was talked about quite a lot.

KENT DAVIES: Through the interviewing process Hussain also found an enthusiasm amongst WFPS participants towards the opportunity to share, learn and improve their skills. 

AMAN HUSSAIN: There is a strong desire for ongoing professional development and learning in terms of skill maintenance in terms of continuing focusing on different workshops like situational awareness or in addition the training they need to do to keep their qualifications, so things on clear communication, effective listening, managing oneself and anxiety and stress in the context of performance. Those are sort of some of the findings that have come out. Other examples are communication. I spoke briefly about just being overwhelmed with different changes in communication and how to communicate most effectively from an organizational perspective.

KENT DAVIES: It’s important to note that Hussain’s research comes at a time when the Winnipeg Fire Paramedic Service are working towards improving workplace culture. In late 2020, the WFPS initiated a Workplace Cultural Assessment survey, the results of which indicated a passive/defensive workplace culture dominated by avoiding conflict and trying to fit in.[vi] As the report outlines, WFPS members are calling for a more constructive, supportive, and cooperative workplace culture. Since then, WFPS has been looking for ways to improve their service; implementing professional development sessions including Equity, Diversity and Inclusion training and taking steps to improve communication amongst their staff.[vii] Hussain believes his research is part of this cultural shift towards increased opportunities for professional development, better communication and better learning.

AMAN HUSSAIN: This is part of the process. I mean– that they’re open to me as an outsider coming in to, you know, observe their employees, their personnel and ultimately serve them. Because I will only do these in the service of ultimately enhancing the professional development of the fire paramedic service. Maybe make comment on how it can become better or identify barriers that might have been, not been talked about. There were really remarkable peer support interactions during this time. Firefighters supporting paramedics, paramedics supporting firefighters. I think there’s this shared purpose of serving the community especially during COVID. And so, partly why there was such a strong desire for example, for professional development was because it gave them opportunities to share. Here are some of the challenges that we’re facing. How can we solve these things together? How can we manage them better together? Why this type of research, I think, is so impactful and important because it’s ultimately in the service of firefighters and paramedics in the city of Winnipeg.

 

KENT DAVIES: So, back to the research question. “How do we learn more effectively while working in a high stress work environment?” For Hussain, it beings with fostering an environment of psychological safety. The term, coined by Harvard Business School professor Dr. Amy Edmondson, psychological safety is the belief that one can speak up without risk of punishment or humiliation has been established as a critical driver of learning, high-quality decision making, healthy interpersonal relationships, greater innovation, and better performance in organizations.[viii]

AMAN HUSSAIN: So, in contexts that are NUTS characterized by high risk and interdependence, you know you require a psychologically safe workplace to have really good outcomes.

KENT DAVIES: Dr. Aman Huassain’s research re-enforces this notion. Through a combination of informal and formal mentorships, peer support, effective communication, sharing challenges, opportunities for professional development and changing mindsets from a perceived threat to a perceived challenge, learning can occur more effectively in a high stress working environment. And while the COVID-19 pandemic may have disrupted opportunities for effective learning, the recent study with WPFS demonstrates the eagerness of its members to strengthen the organization through better communication strategies and professional development opportunities. This project is important to Hussain, not only because he values the opportunity to, “serve those who serve,” but he gets to work in an emerging field of research that has previously underrepresented the experiences of paramedics. Hussain hopes with his research with the WFPS and the work of organizations like the McNally project which specializes in paramedicine scholarship will help paramedicine research grow in Canada.[ix] And while his research has focused primarily on NUTS workplaces, Hussain believes we can all learn from it regardless of our profession.

AMAN HUSSAIN: You know, a saying that my mentor Cal Botterill always said was people first, performers second, and that always stuck with me. And the challenges that we all face as human beings are universal and the way we experience them also are universal. We all of us, when we were exposed to a challenging or threatening situation, have physiological and cognitive reactions to those perceived threats and challenges. And so. I do think a lot of these are applicable. You know, I teach currently a course called Psychological Skills in Sport and Life. And a lot of the current work that I’m doing with paramedics, firefighters, performing artists, physicians, I talk about it currently with my students, for example. How they approach setting up time to do an assignment or maintaining focus during the writing of a test, for example, that is a performance and the thing that gets in the way of most performers is their own selves, their own perceptions of the challenges, the threats that they are facing. And so, if we can switch a perceived threat to a perceived challenge that is much more, you know, helpful, you know, regardless of whether it’s a type of patient that I’ve never interacted with in the context of emergency medicine or performing in front of others in the context of performing arts or sitting down to write a test that you don’t feel ready for. All of these things are potentially threatening or can be perceived as a challenge. You know, and so there are these ties that bind and you know, there are ways that we can prepare through ongoing learning and professional development. And so those are again, some of the things that I attempt to share when I do disseminate my findings.

 

KENT DAVIES: You’ve been listening to Research Question. Research Question is produced by the University of Winnipeg Research Office and Oral History Centre.

The University of Winnipeg is located on Treaty 1 Territory, the heartland of the Metis people.

Written, narrated and produced by Kent Davies.

Our theme music is by Lee Rosevere.

For more information regarding Aman Hussain’s research publications, please see the selected readings section on our Research Question episode page.

For more on University of Winnipeg research, go to uwinnipeg.ca/research

For more information on the University of Winnipeg oral history centre, and the work that we do, go to oralhistorycentre.ca.

Thanks for listening.

 

[i] Sonia Lupien. Well stressed: Manage stress before it turns toxic. (John Wiley & Sons, 2012), 133-140; “Recipe For Stress,” Centre for Studies on Human Stress, accessed March 14, 2022.

[ii] Aman Hussain. “Stories of becoming an emergency medicine physician.” PhD diss, University of Queensland, 2017.

[iii] Aman Hussain. “Stories of becoming an emergency medicine physician.” PhD diss, University of Queensland, 2017. Aman Hussain, Tony Rossi, and Steven Rynne. “Learning in the ED: chaos, partners and paradoxes.” Journal of Workplace Learning (2019)

[iv] Jonathan Wilbiks, Lisa A. Best, Moira A. Law, and Sean P. Roach. “Evaluating the mental health and well-being of Canadian healthcare workers during the COVID-19 outbreak.” In Healthcare Management Forum, vol. 34, no. 4, pp. 205-210.

[v] “UWinnipeg researchers awarded SSHRC Partnership Engage Grants,” accessed March 14, 2022.

[vi] “Organizational Culture Inventory OCI Detailed Report: Winnipeg Fire Paramedic Service,” Human Synergistics International, data by Robert A. Cooke, Janet L. Szumal, and J.C. Lafferty, accessed March 14, 2022; Sam Samson, “Staff survey suggests Winnipeg Fire Paramedic Service workplace culture is ‘passive and defensive,’” CBC News Manitoba, January 31, 2022. Accessed March 15, 2022.

[vii] “Joint Statement on Workplace Cultural Assessment,” Winnipeg Fire Paramedic Service, accessed March 15, 2022. Sam Samson, “Staff survey suggests Winnipeg Fire Paramedic Service workplace culture is ‘passive and defensive,’” CBC News Manitoba, January 31, 2022. Accessed March 15, 2022.

[viii] Amy Edmondson. “Psychological Safety and Learning Behavior in Work Teams.” Administrative Science Quarterly. 1999;44(2):350-383; Ingrid M. Nembhard and Amy C. Edmondson. “Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams.” Journal of Organizational Behavior: The International Journal of Industrial, Occupational and Organizational Psychology and Behavior 27, no. 7 (2006): 941-966; Amy Edmondson, Monica Higgins, Sara Singer, and Jennie Weiner. “Understanding psychological safety in health care and education organizations: a comparative perspective.” Research in Human Development 13, no. 1 (2016): 65-83.

[ix] “McNally Project,” accessed March 14, 2022.