About the Data
Survey invitations were e-mailed to 3,551 organizations. Some 273 organizations (N=273) initiated the Web-based survey, reflecting a return rate of 7.7%. Efforts were made to ensure a representative sample of participation from provider organizations in each region and across all system model designs (see Figure 1). Figure 2 shows the breakdown of provider types and their call volumes.
The survey included 151 questions, many of which asked for multiple pieces of information. It covered a broad base of subject areas, including recruitment, retention, benefits, the economy and salaries. Each agency shared internal information that may not be publicly released or may be proprietary, and the confidentiality of the respondents is honored. The data analyses are reported in aggregate and do not isolate individual organizations.
Although accuracy is a primary goal, this is not a scientific study and has limitations. As with any survey, the results are only as good as the data received. All qualifying surveys were included in the final data mining. In some instances, data was limited, not available, or not applicable for all respondents. In other instances, questions asked respondents to "check all that apply," so attempts to total some percentages will thus result in a tally greater than 100%.
the close of July, the unemployment rate in the U.S. was 9.7%—the highest for the month in nearly two decades. Emergency services organizations nationwide saw substantial cuts in tax subsidies. Frontline layoffs and furloughs became regular news for far too many communities. And reality has set in that the economic downturn is a serious issue, and we may be seeing only the beginning.
Each year for more than a quarter century, JEMS has surveyed EMS organizations nationwide regarding compensation and workplace practices. Started as a tool to help organizations benchmark salaries, the survey has grown to provide an unparalleled view into today’s EMS workplace and serve EMS leaders, human resources professionals, and individual EMTs and paramedics to better understand the EMS field.
* Half (49.7%) of respondents reported a decrease in operating budgets in the past 12 months, with the median being a 10% reduction. Twenty-two percent (22.2%) had no change and 24.2% had a median increase of 5%.
Economic Impact: Year One of … ?
For many, the past year has been tough. If you haven’t been directly affected by the economy, someone in your family or neighborhood probably has. State to state, communities are feeling the pinch as city and county budgets are being cut. Whether you work for a public or private organization, you’re feeling the impact. One major concern facing many is that the current decisions are being made on predictions or best guesses, but no one’s really sure of the true numbers of how bad it really is or will get. That’ll come next year, and things could get much worse.
This year, our survey asked respondents several questions about how the economy is influencing their organizations. The following is a summary of what was shared.
Half (49.7%) of respondents reported a decrease in their operating budgets in the past 12 months with a 10% median reduction. Twenty-two percent (22.2%) had no change, and 24.2% had a median increase of 5%. Changes that have resulted from budget shrinkage include reducing overtime (64.4%), reducing or eliminating travel (62.6%), delaying pay-for-performance (37.9%) and cost-of-living increases (32.8%) and reducing or eliminating professional development (26.2%). Thankfully, only a relatively small sample has had to reduce unit hours (10.3%), cut pay (12.1%), or lay off (7.5%) or furlough (7.5%) employees.
With the cost of personnel being a large segment of any budget, it’s common to see staff cuts and hiring freezes as part of the strategy to deal with a budget shortfall. One in four (26.9%) organizations report they are being forced to either slow hiring (15.6%) or completely stop (11.3%). Those that continue to recruit indicate they’re cutting practices that require funding, such as advertising in trade journals (18.0%), at EMS conferences (17.6%) and non-EMS job sites (e.g., Monster.com, careerbuilder.com) (9.5%).
Sixteen (15.9%) percent of organizations indicate the economic situation is driving reconsideration of staffing, specifically ALS units. Many are considering alternatives to two-paramedic staffing in favor of using an EMT and a Paramedic. The economy has also caused 71.3% of the agencies responding to evaluate their production and utilization of unit hours. This consideration has resulted in no changes for 41.1% of agencies, but 30.2% of agencies are making changes to better match resources to demand based on their historical demand analysis.
Training and development is a frequently sacrificed line item in lean times. Thankfully, 75.5% of respondents have been able to maintain their continuing education commitments. Those who have made changes have increased the use of online offerings (9.4%), reduced content down to minimum requirements (7.2%) and stopped paying employees overtime for their attendance (2.6%).
Employee pay and benefits are also a major chunk of every budget (and will be discussed more later). There’s no concrete evidence that base salaries have been cut, although, anecdotally, many communities are reducing overtime and freezing merit and cost-of-living increases, which do impact an employee’s compensation. In many communities, labor organizations are either being asked to accept renegotiations of contracts and cuts or are proactively engaging community leaders in talks. In jurisdictions with organized labor, 20.2% report labor is making concessions and agreeing to cuts, and 40.5% are accepting limited to no increases. Forty percent (39.3%) continue to push for increases in pay and benefits regardless of economic strains. In some communities, this has rightfully been met with significant public backlash.
Survey respondents report that cuts are occurring in benefits, resulting in reductions or complete termination. Almost a quarter (21.0%) indicate reductions in major medical for employees (10.7%) and their families (10.3%). Tuition reimbursement (9.2%) for EMS training (4.6%) and college (4.6%), dental coverage (4.1%), retirement contributions (3.8%), optical/vision (3.7%), and discretionary personal time (2.5%) have also been reduced. Complete termination of a benefit is pretty light, with the biggest hit being tuition reimbursement (4.6%) for college (3.4%) and EMS training (1.2%).
The economic reality has impacted many people’s retirement plans. As the market fell, so did the value of many retirement funds. Fifteen percent (14.8%) of organizations report having employees slated to retire who have opted to postpone their plans to allow time for the market to recover.
Where the economy will take emergency services organizations and their employees in the next few years is uncertain. What is certain is that this is just the first year of many. Those that will fare the best are those that take the downturn as an opportunity to act and be proactive in reducing costs and increasing efficiencies. Those that hold on tight, take a deep gasp and simply hope are likely to be the biggest losers in years to come.
Find Them, Get Them & Keep Them
Intuitively, we know that providing high-quality service and top-notch care requires compassionate, competent personnel. Many organizations purport to be very employee focused, but actual actions don’t always reflect that. The survey asks organizations about the activities and processes used to hire great people and keep them as long-term, high-performing contributors.
Only a third of organizations (34.6%) have personnel dedicated to recruiting. Fewer than one in 10 (8.7%) rely on a professional recruiter versus internal EMS personnel assigned to the task (25.9%).
Employee referral (33.0%) remains the leading method for attracting the most qualified candidates. The organization’s public Web site (26.3%) and local EMS training programs (21.6%) were close favorites. The least effective methods reported were postings on non-EMS job sites like Monster.com or careerbuilder.com (1.4%), trade journal advertisement (1.4%) and EMS conference booths (0.3%).
Hiring good people and then training them to be proficient is reported to be preferred (71.1%) over focusing on experience and credentials first (29.0%). Almost half (47.7%) report perceiving a paramedic shortage exists (at least in their area). The other half of respondents don’t see a shortage of paramedics and either have not had trouble recruiting for open positions (26.5%) or see the non-ambulance transport role demand for paramedics (e.g., first response, emergency departments) as drawing the resource.
Seventy percent (69.7%) of organizations use part-time personnel to complement full-time staffing. More than a third (35.5%) have seen an increase in interest for part-time positions.
Many organizations long ago made the operational decision to staff ALS units with two paramedics versus the more common standard of an EMT and a paramedic. Ten percent (10.1%) are now converting to either intermediate/paramedic staffing (3.4%) or EMT/paramedic staffing (6.7%).
Organizations report using ongoing, rolling hiring assessments (41.8%) and scheduled assessment centers (36.4%) where hiring activities are bundled several times per year; twenty-two percent (21.8%) report doing a combination of both. Common hiring activities include reference (91.9%) and criminal background (91.6%) checks, interviews by human resources or administration (89.4%), drug screening (83.5%) and interviews with potential peer medics (64.1%).
When it comes to actually assessing applicants’ ability to do the job, assessments include lifting and moving (58.8%) and physical agility (56.4%) testing, multiple-choice clinical tests (42.3%), clinical scenario tests (32.4%) and practical scenarios (28.9%).
Two-thirds (66.8%) of organizations report diversity as an important part of their recruiting, and only a little more than half (54.5%) indicate their workforce is reflective of the community it serves. Nearly half (46.2%) state diversity is a strategic goal of recruiting, but only 25.8% have actually altered their methods to increase the diversity of new hires.
Generally, the cost to recruit a new employee can eclipse the cost of retaining them. Some estimates are 50–200% of a position’s annual salary, and the cost increases the higher level the position is. The cost is a combination of direct recruiting expenses and the lost productivity and overtime. Despite the costs, two-thirds (68.0%) of organizations reported having no retention plan. Thirty-two percent (32.0%) offer some kind of retention bonus.
One core activity to assist in employee retention is employee surveys to understand satisfaction rates and engage in dialogue around how to make the workplace better. Just under half (48.7%) of organizations report conducting regular employee surveys either in house (29.1%) or through an impartial third party (19.6%).
The majority of organizations responding to the survey report that employee separations are level (64.0%); 22.3% have seen a decrease, while 13.8% have witnessed an increase. The most common reasons for separation include leaving for another EMS organization—31.7% to the fire service and 16.1% to another ambulance service. Going back to school is the case for 16.5%, but 22.8% are leaving the profession altogether.
Exit interviews with departing employees are important because they help you gain insight into your organization. Eight of 10 (78.3%) conduct some form of exit activity with separating employees, with the most common being an in-person interview (74.7%).
The process and care an organization uses to recruit, hire and retain employees says a lot about the values and focus of that organization. Best practices organizations focus more on finding great people and keeping them. Investment in a strong workforce always leads to a good return.
One of the primary considerations for any employee is their compensation. Compensation includes pay, but also the benefits received as part of full-time employment.
The salary tables reflect reported mean salaries by total call volume and are broken down by the 10 federal regions. Salaries are shown using the percentile method, which helps the reader see how their wages compare. The range from the 25th percentile to the 75th percentile is referred to as the fair market value. For example, if a paramedic from Kentucky makes $30,000, that’s just above the mean and falls in the fair market range of $24,760 to $35,712 for Region IV (see Figures 3 and 4). All wages are adjusted to reflect a 40-hour workweek for comparison; see Figure 5 (p. 36) for instructions on calculating wages for comparison to alternative shift lengths.
It’s important to note that the data is based on 2008 data—pre-downturn—so it doesn’t reflect any changes that may be occurring now based on the economy. If salaries are adjusted due to the economic environment, you’ll have to wait until next year’s data to see the impact.
In addition to salary, a large portion of an employee’s total compensation includes benefits, such as health and dental insurance and retirement. Benefits may be entirely paid for by the employer, partially paid by the employer or offered to an employee at their own expense. Figure 6 (p. 38) provides a complete breakdown of the benefits queried in this year’s survey.
Early indications are that salaries will not see increases this year, and some communities may see decreases. Also, organizations are evaluating cuts to benefits, which affect an employee’s total compensation. It’s important that organizations work with employees so they understand the complete impact and future forecast and can adjust their lifestyles and spending accordingly.
EMS as a Workplace?
When it comes to your workplace, core considerations are more than just who your partner is and what ambulance you’re on. Workplace factors are important to each employee and can play a role in job satisfaction and employer choice. Unfortunately, in many cases, practices are based on tradition or the status quo, and workplace decisions may not be aimed at employee safety and well-being.
One of the biggest challenges in any organization is scheduling. Scheduling resources and people is a delicate balancing act that requires up-to-date knowledge of the organization’s call demand geographically and throughout the day, blended with a complex method for putting the right people in the right places for the operation and the staff themselves. It’s a process that’s hard to get right. One third of agencies (32.2%) use a 56-hour workweek; this is 16 hours longer than the traditional American workweek and reflects the high utilization of 24-hour shift schedules. More than a dozen different workweek lengths were reported, with the most common being 48 hours (27.6%), 40 hours (16.5%) and 36 hours (6.5%).
Fifty-nine (59.1%) percent of organizations report they use only one shift length, and 40.9% use a mixture of shifts, which adds flexibility and provides better matching of supply to demand. Sadly, 54.2% continue to use 24-hour shifts as their dominant shift. This is reflective of the high number of smaller or rural services with lower call volumes and the fire service, which traditionally models ambulance shifting after that of the fire-focused team members. The continual reliance on 24-hour staffing should not be seen as an endorsement of the shift type; although they’re easier to manage and can be economical, they’re not employee friendly and there are serious safety concerns when they are used in higher call-volume areas or when providers are allowed to do more than one shift in a row. Common shorter shifts include 12-hour (29.2%), 10-hour (3.5%) and eight-hour (3.5%) shifts.
When a person works is a major factor in their job satisfaction, and the needs of an employee change over time with their life situation (e.g., college, kids, etc.). Organizations must be mindful of the process they use to assign shift schedules and provide paid time off. This is especially true of younger generations, who are not as willing to accept old methods. It was surprising to learn that in 38.4% of organizations, management alone makes the decision about shift assignments. Many organizations (27.5%) use processes that blend an employee’s length of service with their performance to determine shift assignments. Twenty-seven percent (26.7%) still default to seniority to make shift decisions. Unfortunately, this frequently rewards the ability to remain employed versus performance and can discourage newer, high-performing employees.
For our mental health and well-being, everybody needs to take some time off and get away from the daily grind. Americans are notorious for not taking vacation in comparison to our industrialized peer countries. Fifty-seven percent (56.6%) of organizations report their employees use less than their accrued vacation leave each year. They’ve got the time; they’re just not taking it. One common issue found in emergency services organizations are the challenges of getting time off; some 63.1% of respondents report that employees can use their time when they want to, but it requires a process that includes very advance notice. Only a third (35.3%) say it can be used when needed and is easy to take.
Developing our Workforce
Developing employees is critical for creating highly skilled personnel, and research shows it’s heavily tied to younger generations’ satisfaction and job selection. But most organizations rarely venture from the basics, and meeting continuing education (CE) hours for recertification and training dollars are often the first to be cut in tough times, way before the chief’s vehicle. Training and development builds skills and knowledge, improves quality and aids in retention, so why is it such a low priority for us?
When a new employee enters an organization, it’s common to have a probationary or orientation period. The timeframe may be pre-set or based on experience or competency. Almost two-thirds of organizations (62.7%) report their orientation period to be 12 weeks or less, with 12 weeks (15.7%) being the most common, followed by eight weeks (7.8%), four weeks (10.8%) and two weeks (7.8%). Thirty percent (29.8%) report 24 weeks or more.
Fifty-three percent (53.0%) of responding organizations assign new employees to a field training officer who assesses and mentors them to a pre-defined level of proficiency or competency; 47.0% assign them to a senior provider until they are determined to be able to function independently. Twenty-eight percent (28.0%) of organizations report that new employees must complete an interview with the medical control physician before being cleared to practice.
Employers appear to see the importance of providing CE, and 82.6% report they take the brunt of the financial responsibility and foot the bill for CE expenses. Employees are on their own in 17.4% of the responding organizations. Although many organizations seem to be opting for less frequent training, 53.2% of survey respondents offer CE on a monthly basis, and 16.0% offer it even more frequently. Seventeen percent (17.1%) provide on-demand or asynchronous training. Content areas receiving the greatest attention include documentation (90.4%), life-threatening clinical care (88.1%), care protocols (86.6%), policies and procedures (79.3%), emergency driving (75.1%) and non-life-threatening clinical care (73.6%).
One concern continually raised in meeting rooms and on e-mail groups nationwide is skill exposure for paramedics. Although published literature seems to indicate field providers are not adequately exposed to live patients to maintain skill proficiency (e.g., in endotracheal intubation), 73.8% of the survey respondents believe exposure is adequate in their system. Eighty-five (86.6%) percent report they track skill exposure and success. This finding is worthy of further study, because it’s not consistent with the literature.
One approach to addressing limited live exposure is to use simulation-based practice and competency confirmation. Although there are some fabulous technologically advanced tools, even just the basic old manikin can be useful. A third (33.3%) of organizations do just that—use traditional manikins—and 21.4% are using high-tech simulation manikins. Thirty-nine (39.1%) percent use simulation manikins in concert with other methods. Eighty-two (82.1%) percent of respondents administer skill proficiency practice and competency confirmation. A third (33.9%) confirm skills annually; some are more frequent, including biannually (10.8%), quarterly (14.3%) and even monthly (8.76%). Eighteen percent (17.9%) have no program in place.
Emergency services are important to public safety, public health and the entire health-care system. Frontline providers have great passion for taking care of patients, and leaders struggle daily to ensure reliable, quality care and transport. Central to those efforts is the people. Although we profess to "get that," we’re still behind mainstream industries in designing organizations that meet the needs of the customer consistently and aim to create and maintain a safe workplace. Emergency services will continue to struggle as a desirable career until it moves forward. The current economic constraints will either be a great opportunity for organizations to take a step forward and creatively adjust priorities, or it will be a large step backward if we hold on to the status quo. Which kind of organization is yours?
The author acknowledges the great support of the Fitch project team members and their contributions to the article: Sharon Conroy, Melissa Addison, Cindy Jackson and Michael Greene