Background <p>Paramedics in emergency medical services (EMS) work in high-demand environments in which occupational well-being is closely linked to patient safety and workforce sustainability. While transformational leadership has been associated with positive staff outcomes in health care, evidence regarding its associations with work engagement and occupational well-being in prehospital EMS remains limited. This study examines transformational leadership in Finnish EMS in relation to paramedics’ work engagement and occupational well-being, including whether the association between transformational leadership and occupational well-being is statistically consistent with an indirect pathway involving work engagement.</p> Methods <p>A cross-sectional online survey was conducted among 322 Finnish paramedics working in EMS at basic or advanced levels. Transformational leadership was assessed using the 43-item Transformational Leadership Scale, work engagement using the Utrecht Work Engagement Scale (UWES-9), and occupational well-being using a single-item self-rated numeric scale (4–10). Descriptive statistics, Pearson correlations, and hierarchical multiple regression analyses were conducted, adjusting for age, gender, education level, professional title, and years of EMS experience. Bootstrap resampling (5,000 samples) was used to examine whether the association between transformational leadership and occupational well-being was statistically consistent with an indirect pathway involving work engagement.</p> Results <p>Transformational leadership had a mean score of 2.75 (SD = 1.03, range 1–5). Leadership ethics received the highest ratings, whereas feedback and rewards were rated lowest. In multiple regression analyses, transformational leadership was positively associated with work engagement (β = 0.437, <i>p</i> &lt;.001) and occupational well-being (β = 0.501, <i>p</i> &lt;.001) after controlling for demographic factors. Work engagement was positively associated with occupational well-being (<i>p</i> &lt;.001). When work engagement was added to the model, the association between transformational leadership and occupational well-being decreased but remained statistically significant, suggesting that the association was statistically consistent with an indirect pathway involving work engagement.</p> Conclusions <p>Transformational leadership was positively associated with work engagement and occupational well-being among Finnish paramedics in EMS. The association between transformational leadership and occupational well-being was statistically consistent with an indirect pathway involving work engagement. However, causal or mediational conclusions cannot be drawn due to the cross-sectional design. From a health services perspective, the findings suggest that leadership may represent a key organizational resource for supporting workforce well-being and performance in high-demand EMS systems.</p>