The “JEMS Salary & Workplace Survey” is a joint research project in collaboration with Fitch & Associates, LLC (www.fitchassoc.com). For 27 years, Fitch & Associates has been the leading international emergency services consulting firm and served a diverse range of clients.
About the Data
JEMS Salary & Workplace Survey invitations were e-mailed to 2,599 organizations. Two hundred eighty-one organizations (n=281) initiated the web-based survey, reflecting a return rate of 11%.
Figure 1 (p. 44) shows the breakdown of provider types and call volumes. Total respondents are noted as “n=” for each data set throughout the article. In some instances, data was limited, not available or not applicable for all respondents. This means “n” can change from data set to data set.
Through the survey invitations, efforts were made to ensure a representative sample of participation from provider organizations in each region of the U.S. and across all system model designs. Figure 2 (p. 44), displays this data in a map. All 10 federal regions are represented in this year’s data, but four states were not represented in the returned surveys.
A significant change from the prior year’s report is that data is only reported where the number of responses within the selected data set is equal to or exceeds five. This methodology is in conformance with antitrust concerns and generally accepted safe harbor guidelines for U.S. salary surveys.
The figures and tables for 2011 note the number of respondents for each category or question, and when “n” is less than 5, the table indicates “N/A.” As a point of reference, salary tables include a “national average,” which comprises the data across all respondents. Accuracy is the primary focus, yet readers should understand that the survey is based on self-reported data and has limitations specifically related to sample size.
The total number of respondents to each specific statement below is noted at the end of that statement as “n=.”
With an exaggerated groan, Duke Gracie climbs out of the driver’s side of a Flowing Springs EMS (FSEMS) ambulance, squinting into the bright sunlight and pulling his sunglasses down over his eyes. The groan was in response to his partner’s comment, “Give me trauma or give me sleep.” This was the third call they’d received since midnight during a 24-hour shift, and none of the calls involved trauma. As a shift supervisor and field-training officer (FTO) for Flowing Springs EMS, Duke is used to this type of comment from a “rookie” paramedic. In his 30 years on the street, Duke has seen it all and isn’t in a rush to run the “big one” with his trainee partner.
“I’ve got to figure this guy out before I cut him loose,” Duke thinks.
Across the parking lot, FSEMS General Manager Margaret Taylor sees Duke as she hurries toward the administrative office. “Duke, I hope that newbie is ready to be cleared from field orientation. I need him for the new Diamond Lake contract, like, yesterday,” she says. “So let him go, you old dinosaur.”
“Always in a rush,” Duke comments to his former partner. “Good thing you aren’t in the wine-making business.”
Does this sound like a familiar dialogue? Let’s listen to what each person is really thinking during the exchange:
Duke: “I love working in the field. I’ve been a medic as long as I can remember. In this small community, patients are often my friends or extended family. But the long hours, sleepless nights and physical effort of the job is taking a toll, and I’m not sure I can keep up with the pace and train these youngsters. Isn’t there some other way I can use my skills and experience to help patients?”
Maggie: “The constant pressure to do more with less is aggravating. We’ve made it through another year’s budget crisis, and our relationship with the town and the mayor are solid. Duke and I grew up in this system, but he wants to stay on a truck forever. How can we capture his knowledge and experience? Could this community paramedic concept have a future? Duke would be great at that job, but would the hospital see value in the program and be willing to fund it?
The JEMS Salary and Workplace Survey has been conducted in cooperation with Fitch & Associates LLC for 27 years. We’ll provide a review of salaries and workplace practices for 2011 through the story of Flowing Springs Fork Emergency Medical Services, a fictitious “Any Town, U.S.A.” ambulance service, along with Maggie, Duke and his trainee, Dave.
What Does the Future hold?
A 2008 article in the JEMS suggested low reimbursement rates keep EMS pay low.1 Although it may be too soon to see the effect of reimbursement changes on salaries, we know that funding at the federal level for Medicare payments fell below the average cost per transport in urban and super-rural areas in 2007.2
Add to this a new method of calculating the ambulance inflation factor (AIF) applied to Medicare fee schedules and the Patient Protection and Affordable Care Act of 2010 (PPACA), which will apply a productivity adjustment to the AIF and consumer price index (CPI), and we see that doing more with less is the recurrent theme for EMS.
The necessary balance between fiscal austerity (reality) and optimal funding has created a clash between having adequate EMS staff to provide safe patient care and having sustainable EMS operations. The battle in some communities has already been lost. Headlines from Nashua, N.H., read “More than 160 people who work for a local ambulance company will be looking for work in a few weeks,” (Rockingham Regional Ambulance, which is run by St. Joseph Hospital in Nashua, was set to close its doors on Sept. 30.) And headlines in Mount Dora, Fla., tell a similar story, “Hundreds of Lake EMS employees told their company would dissolve on Oct. 1.”3,4
Cities and towns continue their struggle with reduced property taxes and pension funding, and the struggle is affecting EMS. Even the minimal funding provided to volunteer EMS agencies is diminishing.5 More than half (56%) of the 153 responding agencies report a decrease in the past 12 months’ operating budgets, and nearly a fourth (24%) report no change. After factoring in inflation, this translates to 80% of agencies having to provide service with less funding. Unknown effects from pending healthcare reforms lurk in the future to add additional pressure on all EMS provider types.
Vacancies, Recruitment & Hiring
Maggie wonders why, with the current unemployment rate, she still can’t seem to find enough paramedics. “It doesn’t seem like we’ve had a bunch of employee separations, yet we seem to be continually hiring. And then, Duke just won’t cut them lose fast enough,” she thinks.
Outside, Duke sighs as he ends his shift as FTO. “Maggie is sure pressuring me to clear paramedics. If she wants them on their own quicker, we’ve got to start hiring experienced medics,” he thinks.
Maggie and Duke are both correct on these points, according to our recent survey results. One hundred and fourteen agencies reported vacancies, totaling 569 full-time equivalents (FTEs)—an average of just under five vacancies per organization. We were surprised to find 10 agencies with vacancies over 20 FTEs and one reporting 95 openings. Separations are “unchanged” at 67% or “decreased” at 14%, with only 19% of agencies reporting an increase in employees leaving the organization. By region, the most reported vacancies are in Region 3 with the fewest vacancies reported in Region 7 (see Figure 2, p. 44).
The top-rated tools for recruitment included: “Your agency’s website” (25%), followed closely by “employee referrals” (24%) and farming talent from “local EMS programs” (21%). The usual newsprint (less than 2%), trade journals (5%) and mailing lists (8%) are still used, but this use is declining from year to year, according to the survey results. Not mentioned in the survey was the use of social media sites and tools, such as Facebook or LinkedIn, for recruitment purposes. These sites are becoming increasingly popular with EMS crews and can serve as a major recruitment tool.
“Hiring good people is the primary selection criteria; we can educate them on skills and knowledge” continues to be the driving hiring selection criteria for 64% of survey respondents. In contrast, 36% said that “EMS experience and credentials are the primary selection criteria” for hiring. Given the top recruiting methods, this finding isn’t surprising.
The good news is that of the key operational staff positions, communications specialist and EMT-Basic positions are readily filled more than 80% of the time. However, in regard to paramedics, 44% of survey respondents report that “There is a shortage of paramedics available to hire.”
Maggie’s remark about Duke’s age isn’t that far off, according to this year’s survey. He’s one of few paramedics over 50 years of age (4%). Organizations reported fewer than 12% of paramedics are age 41 and over. For communications specialists, 40% fall in the age category 31–35, and 89% are grouped between 26 and 40. EMT-Basics continue as the industry’s “youth,” with the 21–25 and 26–30 age groups comprising the majority at 16% and 40% respectively. The question is: Can Duke continue working the field as he ages? If not, what will he do next if he wants to stay “hands-on” with patients?
Employee Orientation & Field Training
“My Millennial/Generation Y trainee needs more orientation and field time,” Duke says to Flowing Springs’ education supervisor. “I’ve barely had him for a month.”
“Not so,” Maggie interrupts. “You’ve had six weeks, and that’s the top amount of time we can spend on field orientation. I haven’t got the budget for more time or, for that matter, for a formal FTO position.” She adds this last part gently, respectful of her former partner.
Based on recent survey results, we’ve observed the list of new employee orientation topics growing. But funding for these new skills and knowledge set isn’t clear from our research. Some agencies commented that they’re reducing classroom and field orientation to minimal levels. This reduction isn’t reflected in the aggregate data: The average duration of field training reported this year is 10 weeks, with some organizations reporting more than 26 weeks (16%), compared with this past year’s average of nine weeks.
We know that most new field training is conducted by pairing trainees with a senior staff member (63%) vs. enrolling them in an official FTO program (37%). Daniel Patterson, PhD, and his team of researchers at the EMS Agency Research Network are looking at teamwork in EMS. Patterson indicated in an abstract published this year in Prehospital Emergency Care that the research may show a link between teamwork and length of time as partners, but he hasn’t published any conclusions yet.6 Teamwork may also have a key patient safety component. For more on this, read the “Fatigue” section, next page.
“Oh for the good old days,” comments Duke, who’s now sitting in front of a computer back at the station. He’s working on a course for continuing education units (CEUs). “I miss pencil, paper, chalk, blackboards and teachers with a big ruler. Now we’ve got a keyboard, mouse and streaming video.”
Maggie listens from the crew kitchen while pouring coffee. “Hey, Duke. Stop complaining,” she says stepping into the crew quarters. “With 26 bases and 300 EMTs and medics, this is the most efficient and cost-effective way to cover all of the CEUs, mandatory and staff development training and ensure that training is consistent.”
Duke stares back at the monitor and mumbles, “How do I know if the medical director is real or just some computer-generated animation?”
Unlike the mythical FSEMS, many organizations continue to use a traditional classroom method for presenting CEU and staff development (43%) vs. a mix of traditional and distributive (50%) or all-distributive (8%) methods. The frequency for CEUs is most often monthly (58%), on demand (14%), quarterly (7%) or semi-annual (3%). Surprisingly, 18% of respondents reported that CEUs were offered greater than once a month.
Duke may be correct in questioning the reality of the FSEMS medical director (MD), because respondents report that interaction between field staff and their MD is low. Less than one-third of EMS personnel meet with a medical director to be cleared from orientation/field training, and the contact drops from there to 21% of EMS staff members who “never meet” with the MD. More than half (54%) meet “only when needed.”
Like other workers today, the EMTs and paramedics at FSEMS wonder about job security. They feel some comfort because they provide an essential public service. Yet in communities all around them, pay and benefits are being cut even for
police, fire and EMS.
Figures 3 and 4 (p. 45 and 46, respectively) display reported salary data from the sample for a multitude of core EMS positions. The data is stratified by call volume and geographic region. Salary data is presented in percentiles. Salaries between the 25th and the 75th are considered the market range based on the survey sample. All wages are adjusted to reflect a 40-hour workweek for comparison. See Figure 5 (p. 46) for instructions on calculating wages for comparison to alternative shift lengths.
Our seasoned shift supervisor, Duke, has carefully planned his financial life, but it heavily depends on maintaining his pay level and being able to work some amount of overtime or standby duty each month. He has twin daughters in college. From a strictly financial perspective, he’s looking forward to their graduation next year. Any reduction in pay or hours could shake the foundation of his plan and possibly force him to work a few more years than he would like or take on a second job.
He worries the company’s retirement plan may not be as sound as it could be and that future Medicare cuts could not only affect the company’s financial stability, but his retirement as well. Duke downs another dose of antacid to settle his nervous stomach and allow him to focus on CEUs and that next call.
Of the 147 agencies that responded, 80% provide a retirement plan that’s funded wholly or in part by the employer. Only two agencies answered that the retirement plan is funded wholly by the employee. The 401(k) is another form of retirement plan that, in general, shifts more of the burden of retirement savings to the worker. Of the 142 agencies that responded to the survey question about 401(k) plans, 59% reported that 401(k) plans aren’t applicable to their agency.
Duke’s partner, Dave, is a young man who doesn’t think too much or, frankly, know much, about retirement plans and pension funds. He’s on his parents’ health insurance until his next birthday. So for now, he isn’t concerned about health insurance issues. In the coming year, however, he will face a number of decisions because he will need to join the FSEMS medical insurance plan. He isn’t too knowledgeable about what this will mean to his take-home pay, how much he’ll need for the deductible amounts, and exactly what is or isn’t covered on the plan. Will he need to change doctors? Is the FSEMS plan a good one?
Major medical insurance for employees is provided by 95% of survey respondents, and 92% indicate that the agency pays either all or part of the cost of insurance for the individual employee. The survey indicates that nearly 20% of agencies have reduced benefits in their insurance plans.
More important to Dave is that he wants to get married next year. His girlfriend doesn’t currently have medical insurance, and he’s looking forward to being able to include her on the FSEMS plan. He knows that Flowing Springs offers family medical insurance, but he has heard that the employee costs increased substantially this past year. He also wonders whether the plan covers maternity care for the day that he and his new wife decide to have children. Dave decides to talk to his partner, Duke. “He’s taught me more about EMS than I’ll ever let on, and he’s pretty together for an old guy,” Dave thinks.
Duke tells Dave that he should be able to obtain family insurance through Flowing Springs. Of agencies responding to the survey, 93% indicate that major medical insurance is available for family members. Dave’s questions about whether maternity costs are covered are valid because although major medical plans may cover maternity expenses, out-of-pocket costs may vary. Duke tells Dave he should confirm with the FSEMS benefit manager about out-of-pocket costs.
Figure 6 (above) displays a list of benefits commonly and not so commonly offered to employees and the frequency those benefits are offered at no cost or at a subsidized cost to an employee. Figure 7 (p. 48) displays a list of benefits that were reduced or cut in the past 12 months.
After several hours of education on the computer and advising Dave on healthcare, life and the pursuit of happiness, Duke decides he needs a break. He heads out to the ambulance bay to hop on a company-provided treadmill. Exercise, maintaining a good diet and avoiding tobacco are lifestyle choices he has made in favor of good health and longevity. As he punches in age for a custom workout on the treadmill, he pauses. “Fifty-two years old, and a picture of health,” he says out loud to no one in particular. “Now if I could only get a good night’s sleep. ... ”
EMS personnel work a variety of shifts in the provision of 24/7 service. The nature of EMS duty often requires overnight shifts and sleep interruption. Nocturnal sleep disturbances, even with attempted daytime sleep recovery, create a disruption in the circadian rhythm. Sleep deprivation impairs the central nervous system and affects appetite, temperature regulation, memory and vigilance. It has been associated with unintentional incidents, such as motor vehicle collisions and occupational injuries.7–9
Fatigue caused by sleep deficit has been shown in numerous studies to have a deleterious effect on cognitive skills.10–11 Duke knows that fatigue due to shift work has been linked with a 36% increase in “serious” medical errors. Additionally, he’s read a recent study that tasks undertaken while fatigued are best completed by teams. Thus Duke’s focus on teamwork with his partner is an important patient safety issue.
Fatigue is not only a patient safety issue, it’s also a challenge in EMS worker health and wellness. Chronic disruption of the circadian rhythm may lead to sleep disorders, which have been linked to serious medical illnesses, including high blood pressure, myocardial infarction, congestive heart failure, stroke, obesity, psychiatric problems that include depression and other mood disorders, attention deficit disorder and mental impairment.12
Of 98 responses, just 32 agencies report a formal policy or plan for fatigue management, while the remaining agencies report none.
On average, employees are allowed to work 40 continuous hours with a maximum reported continuous shift of 96 hours, or four full days. Following the maximum allowable shift duration, employees are required a minimum of four hours off duty (n=2), average 13 hours with a maximum duration of 48 hours (n=2) before returning to work.
It seems Duke isn’t the only EMS worker who lacks sleep, but what is FSEMS supposed to do about this? Maggie identified fatigue as the root cause of a “near-miss” recently involving one of her crew. After that incident, she researched the literature on alertness management.
She found volumes of research on the subject from the air transport industry and a fully prepared education module on alertness management from the National Aeronautics and Space Administration’s Ames Research Center. Best of all, she found it online and the module is free.13 She forwarded the material to her training coordinator for a presentation during next month’s in-service education session with a note to include the content in all future new-field-employee orientation.
Unnervingly Maggie also discovered a new trend in “shift work sleep disorder”—a pharmacological, pick-me-up pill. Recently advertised in numerous EMS, fire and law enforcement periodicals, Nuvigil (generic name armodafinil) has sparked concern by some EMS administrators and medical directors whether a pharmaceutical is the acceptable (or problematic) when used by personnel to improve on-the-job alertness. Maggie hopes that Duke’s triple shot vanilla café latte will keep him awake while she researches this new approach to alertness management.
Speaking of the future, the concept of paramedics providing community health services isn’t a new idea. However, healthcare reform unfolding may provide opportunities for EMS providers to expand care to meet specific needs through community paramedic programs. A community paramedic program is particularly well suited for rural areas with limited medical care availability. EMTs and paramedics can provide care for “emergencies, evaluation, triage, disease management, basic oral and mental health, as well as prevention.”14
To provide this type of care, EMS providers will need to be open to learning new skills and implementing procedures that are different from the typical response mode. An added bonus of such a program is that this is an area where injured, older or expanded-practice medics could continue hands-on care.
It might seem like the fictional Margaret Taylor and Duke Gracie are in disagreement about a lot of things, but they really aren’t. Duke needs an organization that’s on stable and sustainable financial footing to provide him with the literal and figurative vehicle for patient care. Maggie needs employees like Duke, ones whose heads, hands and hearts provide the care and compassion that makes EMS an honorable profession.
Collaboration and synergy, like in cardiac and stroke response between field agencies and healthcare facilities, will bear EMS through the current and future white waters of an uncertain economy and changing healthcare landscape. And the fictional newbie, Dave, needs to feel confident that the organization can weather the coming healthcare changes, provide him with mentors and offer career opportunities to serve patients, as well as provide for his future family. JEMS
Acknowledgment: The authors acknowledge the support and contributions of Fitch project team members Sharon Conroy, Melissa Addison and Cindy Jackson.
Disclosure: The authors are external, expert consultants with the consulting firm Fitch & Associates, LLC (www.fitchassoc.com), which provides emergency service organizational and system audits for communities and individual organizations.
1. Garza M. Low Reimbursement Rates Keep EMS Pay Low. (April 2008). In JEMS.com. Retrieved July 24, 2011 from www.jems.com/article/administration-and-leadership/low-reimbursement-rates-keep-e.
2. King K, Brudevold C, Apter JF, et al. Ambulance Providers: Costs and expected Medicare Margins Vary Greatly. In Government Accountability Office. (May 23, 2007). Retrieved July 24, 2011, from www.gao.gov/new.items/d07383.pdf.
3. WMUR Staff. Rockingham Ambulance Shutting Down. (Aug. 1, 2011). In WMUR 9. Retrieved July 24, 2011, from www.wmur.com/newsarchive/28732524/detail.html.
4. Comas ME. Hundreds of Lake EMS employees told their company will dissolve on Oct. 1. (Aug. 2, 2011). In Orlando Sentinel. Retrieved July 24, 2011, from www.orlandosentinel.com/news/local/lake/os-lk-lake-sumter-ems-20110802,0,7497584.story.
5. Shirvell B. Ambulance Services Facing $15,000 in Budget Cuts. (May 5, 2011). In Stonington-Mystic Patch. Retrieved July 24, 2011, http://stonington.patch.com/articles/ambulance-services-face-15000-in-budget-cuts.
6. Patterson PD, Weaver MD, Weaver S, et al. Emergency medical technician perceptions of teamwork and conflict with familiar and unfamiliar partners. (abstract only.) Prehosp Emerg Care. 2011;15(1):123.
7. Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352(2):125–134.
8. Steele MT, Ma OJ, Watson WA, et al. The occupational risk of motor vehicle collisions for emergency medicine residents. Acad Emerg Med. 1999;6(10):1050–1053.
9. Horwitz IB, McCall BP. The impact of shift work on the risk and severity of injuries for hospital employees: An analysis using Oregon workers’ compensation data. Occup Med (Lond). 2004;54(8):556–563.
10. Rabinbach A. The human motor: Energy, fatigue, and the origins of modernity. Basic Books: New York, N.Y., 1990.
11. Noy YI, Horrey WJ, Popkin SM, et al. Future directions in fatigue and safety research. Accid Anal Prev. 2011;43(2):495–497.
12. Schernhammer ES, Thompson CA. Light at night and health: The perils of rotating shift work. Occup Environ Med. 2011;68(5):310–311.
13. Rosekind MR, Co EL, Neri DF, et al. “Crew Factors in Flight Operations XIV: Alertness management in regional flight operations education module. (February 2002). In NASA. Retrieved July 01, 2010, from http://human-factors.arc.nasa.gov/zteam/PDF_pubs/REGETM_XIV.pdf.
14. North Central EMS Institute. Opportunities to Grow. (2008–2009). In Community Paramedic. Retrieved July 24, 2011, http://www.communityparamedic.org/Paramedics.aspx.
This article originally appeared in October 2011 JEMS as “JEMS 2011 Salary & Workplace Survey: Employees seek stability in unstable market.”