The JEMS 200-City Survey is a joint research project in collaboration with Fitch & Associates, LLC (www.fitchassoc.com). For 25 years, Fitch & Associates has been the leading international emergency services consulting firm and serves a diverse range of clients.
About the Data
Survey invitations were e-mailed to 2,656 organizations. Two hundred and sixty-eight organizations (N=268) initiated the Web-based survey, reflecting a return rate of 10.2%. Figure 1 (to see all figures click on gallery) shows the breakdown of provider types and their call volumes. Efforts were made to ensure a representative sample of participation from provider organizations in each region and across all system model designs (see Figure 2).
The survey included 122 questions, many of which asked for multiple pieces of data. 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 don’t isolate individual organizations.
Although accuracy is a primary aim, this isn’t 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%.
Keisha Johnson sits unusually straight in her chair and holds securely to her application packet. The waiting area is filled with other EMT and paramedic candidates applying for open positions at Page Paramedics, a not-for-profit ambulance service that partners with fire departments to provide emergency ALS transport. Keisha completed her paramedic program in the fall and worked for a small inter-facility transport service on nights and weekends while she went to school, but this would be her first paramedic position and chance to do traditional EMS work.
Keisha is reflective of the enthusiastic and intrinsically motivated young people entering the prehospital medical transport field with expectations of a long and rewarding career. She hopes to join an estimated 200,000 certified caregivers working in EMS and nervously sits with her peers, wondering what the future holds for her and her career.(1)
For more than 25 years, the JEMS Salary & Workplace Survey has queried EMS employers large and small from across the U.S. in hopes this sample can provide insight into current and emerging workplace trends and reliable salary benchmarks. Over the years, this survey has shown an evolution of the profession as workplace practices more closely reflected those of other fields and salaries increased, but still fallen short of parity with other public safety and allied health peers.(1)
In this year’s survey, we’ll follow Keisha Johnson’s EMS career process and attempt to show how today’s EMS organizations should be prepared to welcome and nurture aspiring EMS professionals. Drawing from the self-reported data, you’ll learn from this paramedic’s experience how EMS organizations are or aren’t meeting her needs. For some of you, this may be a little uncomfortable, but hopefully, for many, it will change the way you think about EMS as a job and how we enable great people to be fantastic clinicians.
Recruitment & Selection
As Keisha reached the end of her EMS program, she had a number of prospective employment options in her region, including fire-based, hospital and private ambulance services. Keisha first considered privately owned Page Paramedics after hearing about it from a friend who was already an EMT. Representatives also came to her class to talk about their organization, and some of the staff led skills stations. Like any 20-something, Keisha immediately checked out their Web site, looking for information about the company and its career opportunities.
In two thirds (66.7%) of the services responding to this year’s survey, an employee referral is perceived to be the single most effective way to identify and attract a prospective employee like Keisha. Organizations also know her demographic is Internet-savvy, going straight to the Web to learn about the organization and apply, and 64.2% report the Web site as a strategic method for attracting qualified applicants.
When it comes to active recruiting methods, 54.5% feel recruiting at local EMS training programs are a successful approach. Some have found that traditional methods, such as advertisement and posting of positions on EMS (16.0%) and general job sites (11.6%), listservs (11.6%), trade journals (9.7%) and EMS conference booths (9.3%) alone aren’t producing the desired results.
A key challenge facing EMS organizations is the supply of qualified paramedic candidates like Keisha. The National Highway Traffic Safety Administration EMS Workforce Agenda stated the demand for the EMS workforce will increase overall but was unable to quantify from existing sources whether the current workforce supply was adequate to meet demand and if the pipeline of newly trained and certified people is adequate to meet the need.(1)
In the survey sample, 67.2% of organizations report their recruitment and hiring practices model those of best practice companies, such as Southwest Airlines, Starbucks and Ingvar Kamprad Elmtaryd Agunnaryd (IKEA), by aiming to hire good people as the primary selection criteria, with the belief that training can enhance any skill or knowledge required to achieve the level of proficiency required. Finding those paramedics remains an issue for 43.3% of organizations reporting they perceive a shortage of certified paramedics. More than two dozen organizations report transitioning from double paramedic staffing to one paramedic and an EMT (5.6%) or EMT-Intermediate (3.7%) as a result of the economy (56.0%) and the perceived shortage (44.0%) of certified applicants in their area. Interestingly, 32.0% state it’s not only the shortage of certified, but also qualified applicants driving their decision.
Keisha is looking for a full-time job. She worked part-time for an inter-facility medical transport service while going to school. Seventy percent (70.3%) of the organizations in our sample use part-time staffing, which is ideal to fill demand shifts and to access and provide opportunities to a diverse segment of workers. A third (32.4%) report an increased interest in part-time opportunities.
As a woman and a Millennial (born between 1980–2000), Keisha wants to work for an organization that takes diversity and inclusion very seriously.(2) She hopes Page Paramedics is similar to the 53.4% of organizations in the sample reporting their workforce diversity reflects that of the community it serves. Increasing workforce diversity is reported as a strategic goal of 53.7% of organizations. Two thirds (67.8%) ask employees to self-report their race and sex to aid human resources in assessing diversity. Organizations report an average of 12.0% employees is non-white, and the median is just 5.0%. Women, on the other hand, have a larger presence, with organizations reporting an average of 27.0% of their workforce are women; the median is 30.0%.
After anxiously waiting, Keisha was called back to start the hiring processes. Today’s process is reflective of many organizations and involves multiple components. She’ll start with an interview conducted by an administrative manager or human resources staff person (88.0%). In 59.2% of organizations, EMTs and paramedics she’d work with if hired would also be part of the selection committee. If she can’t get their recommendations, she’s probably not a good fit. In just 17.2% of organizations in the sample, the medical director participates in the interview process as well.
In addition to the interviews, she’ll have to complete a clinical test, which may be classic multiple choice (38.6%) or scenario-based (36.3%), and she may have to take an operational test in multiple-choice (16.1%) or scenario (15.4%) form. Keisha may also have to complete a practical scenario (31.8%) or a multi-tasking exercise (13.1%).
If Page Paramedics is Like Most EMS
organizations, Keisha will be requested to participate in several tests to confirm her candidacy outside of her paramedic knowledge. This includes a criminal background check (94.8%), drug screening (86.9%), a physical agility test (56.2%) and a lifting and moving simulation (48.7%). In addition, human resources will check references (88.0%) and may even contact her previous medical director for insight into skill competency and knowledge (17.2%).
Keisha does well in the hiring process and feels she has a strong chance. The team at Page Paramedics is really impressed with her, but the competition is tough. A week later, she receives a phone call with an offer of employment and she excitedly accepts.
Keisha has been smart with her income and remained relatively debt-free, but she has a few student loans to pay off. Until now, she has remained on her parents’ health insurance, which has helped defer some of her expenses. With her new job, she’ll now generate enough income to provide for herself and receive her benefits from her employer.
Figures 3 and 4 (gallery) display reported salary data from the sample for a multitude of core EMS positions. The data is stratified by call volume and by 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 for instructions on calculating wages for comparison to alternative shift lengths.
Figure 6 (gallery) displays a list of benefits commonly and not-so-commonly offered employees as well as the frequency those benefits are offered at no cost to an employee or at a subsidized cost.
New Employee Orientation & Field Training
Keisha enthusiastically starts work at the beginning of August. Although she completed a respected EMS training program at her local community college, her first days at Page Paramedics will focus on training specific to the organization’s operations and practice of medicine. In addition, she will be required to complete a field orientation process to confirm her proficiency and acclimate her to the appropriate ways to deliver care. The average number of orientation hours in the survey sample was 238 hours, or roughly six 40-hour weeks; the median orientation was 98 hours or just under two and a half weeks.
New employee orientations vary from organization to organization. If the survey sample is reflective of the norm, Keisha can expect to spend time in the classroom learning about policies and procedures (97.7%), proper patient care documentation (93.6%), emergency driving (90.2%), care protocols (87.2%), organizational values (82.6%) and customer service (81.9%). She may also refresh or learn the proper way to use mapping tools (77.7%), to lift and move patients (77.4%) and do basic vehicle maintenance (70.2%).
Page Paramedics, like the majority of organizations, is focused on preparedness, so she’s likely to learn about the National Incident Management System (NIMS) (69.1%), hazardous materials (62.7%), disaster/mass casualty incident management (62.6%) and weapons of mass destruction (43.0%). Other less-common areas she may spend time learning about include medical billing (47.2%), critical-thinking skills (43.0%) and conflict resolution (34.7%).
Although classroom learning is essential, Keisha was eager to get out into the field. Fortunately for her, Page Paramedics is more progressive than the norm and assigned her to a field training officer (FTO) (47.2%), who assessed her proficiency and mentored her to a pre-defined proficiency and competency level. Half (49.1%) of the survey sample report a new employee like Keisha can spend four or more weeks completing the clearance process and be fully functional and an independent member of the front-line staff.
Keisha enjoyed the orientation program and tried hard to absorb the new material and learning specific to Page Paramedics. Her FTO helped her make the transition to the field. With each call, she became more proficient and comfortable. Her FTO observed her progress and signed her off at each stage. Once Keisha was recommended to complete the clearance process, Page Paramedics joined just more than a quarter (27.7%) of agencies that require new employees to sit down with the medical director for a final clinical clearance before a medic hits the streets.
Keisha learned early on that her initial EMS program provided only a baseline for her learning and, in order to be a solid medic, she will need to continually sharpen her skills and knowledge. This was important for her satisfaction and growth, but also it’s for her patients.
Keisha was lucky because Page Paramedics is committed to frequent continuing education (CE) offered in diverse delivery methods, including classroom and online. Monthly CE is the norm for the majority (56.8%) of the survey sample. For more than a quarter of the organizations, monthly isn’t enough, and CE is offered either more frequently (17.3%) or in an on-demand or asynchronous (e.g., Internet) method (11.3%). Unfortunately, 14.7% report offering CE less frequently.
Organizations are evenly split as to whether they take responsibility for tracking and retaining CE records (49.3%) or defer that responsibility to the individual employee (50.8%).
In 84.3% of the sample, the organization picks up the majority of the direct costs for their employees’ CE. Although 66.9% report the economy hasn’t yet had an impact on CE offerings, 12.4% have reduced offerings to the minimum required, and 12.4% have increased the use of online options. A handful of organizations (1.9%) have passed some or all of the cost onto the employee by not paying them to attend and, in one organization, shifting the complete financial burden to the employee.
Although Page Paramedics offers Keisha great training exposure, she knows getting adequate live patient contacts to maintain skill exposure and proficiency is an ongoing challenge for any medic. The clinical leads at her company aren’t similar to 73.1% of those in the survey sample that believe medics receive adequate exposure to maintain their skills; more than a quarter (26.9%) report otherwise.
Measurement of both skill exposure and success rates occurs in 72.1% of the organizations, but 17.4% don’t track any data. Although 20.1% of organizations report not having any programs in place to practice skills and confirm competency, 28.8% do so annually, and 41.28% are even more frequent—including biannually (12.9%), quarterly (17.4%) or even monthly (11.0%).
The most common approach is to practice on a traditional (33.9%) or simulation (22.0%) manikin; more than a third (35.1%) blend simulation manikins with another method.
Keisha loves to learn, and Page Paramedics’ staff development plan is more than adequate to meet her needs. The blend of face-to-face and alternative CE fits well with her learning style and allows her flexibility, so she can balance her work and personal life. She sets an ambitious goal to participate in all training offered to her.
Health & Safety
When Keisha told her dad—a retired firefighter—that she wanted to be a paramedic, he was proud she wanted to continue the family legacy in emergency services. He also had some concerns. He knew EMS was a hard job with risks and felt EMS wasn’t as health-and-fitness focused as police and fire. Keisha took his worries to heart and is interested and focused on her safety and overall well-being.
If Page Paramedics is similar to our sample, one out of every five employees will experience an on-the-job injury each year, resulting in an average of 90 lost work days across the organization. Overexertion from lifting is reported as being the cause of an average of half (54.5%) of injuries and being more than twice as likely as the next category of injury, which is falls (18.4%). Another major risk to EMS caregivers is emergency vehicle crashes, which were reported at a mean rate of 5.1 per 100,000 fleet miles traveled.
Lifting injuries and vehicle crashes are surface safety issues we all know exist, but the white elephants in the room include fatigue management, stress management and lifestyle factors. Only a little more than a third (38.1%) of the sample has a formal fatigue management policy or plan, which included establishing maximum consecutive work hours (average 38.6 hours, 70.3%), minimum recovery hours between work assignments (average 11 hours, 62.5%), and the minimum number of hours after drinking alcohol that must pass before reporting for duty (average 9.9 hours, 57.5%).
Keisha is fortunate that the leadership at Page Paramedics is familiar with research on EMS lifestyle factors, including smoking and obesity. She has never smoked, but a reported 35.5% of EMS professionals have, and female smokers represent a higher percentage than males in EMS.(3) Although half of the personnel no longer smoke, 98.0% attempted to quit during the previous 12 months of this survey. Keisha’s body mass index (BMI) is 20, which is well within normal range; 25–30 is considered overweight and 30 and over is obese.(4) EMS personnel in one study sample were reported to have an average BMI of 28.(5)
To combat these lifestyle factors in the workforce, Page Paramedics joined the 24.8% of organizations in the survey sample that offer lifestyle incentives or penalties as part of the health coverage at their organization.
Page Paramedics is also proactive in stress management, recognizing stress as a major risk to health and well-being of its staff6 They train all personnel to manage stress from a physiological basis (e.g., cardiac coherence techniques), offer critical incident stress debriefing and employee assistance in which counselors utilize eye movement desensitization and reprocessing for high-stress incidents. Only 18.7% of organizations reported proactive stress management programs.
Because Keisha is athletic, has never smoked and is a light social drinker, she appreciates that Page Paramedics includes health promotion as part of her health coverage. If Keisha maintains her physical condition, follows the policy to limit fatigue and makes safe choices when on the scene of a call or while operating the ambulance, she has a good shot at reducing her risk and ensuring a long career, and Page Paramedics will support her every step of the way.
Keisha is fortunate to not have a lot of expenses, but she does have some debt from her EMS training. Like most Americans, she’s conscious of the current economic climate and knows it can impact her employer. She feels privileged to have a full-time job but wonders how the economy might alter her total compensation at Page Paramedics.
The economy continues to be a major issue for communities large and small. This is especially true for communities that rely on local tax subsidies for funding as consumer spending remains stagnant.(7)
Operating budgets have been cut by an average of 9.0% for 43.7% of the responding agencies. This has resulted in reducing overtime (65.5%), reducing or eliminating travel (55.4%) and delaying cost-of-living increases (43.5%) and pay for performance (32.2%). More extreme actions, such as pay cuts (12.4%), layoffs (10.7%), furloughs (10.2%) and work hour reductions (9.0%), are less common but present (see Figure 7, gallery)
Keisha, like most people entering the industry, is starting an exciting journey. If she’s lucky, Page Paramedics will remain at the leading edge and provide a sustainable and enjoyable work experience.
The industry as a whole continues to offer opportunity and improvement to benchmark well with other public safety and allied health professions. If EMS organizations keep improving the workplace, Keisha and her peers will enjoy a rewarding career and make a lasting difference in their communities and with each patient they encounter. JEMS
Acknowledgement: The authors acknowledge the great support of the Fitch project team members and their contributions to the article: 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. National Highway Traffic Safety Administration. EMS Workforce for the 21st Century: A National Assessment.
2. Zemke R, Raines C, Filipczak B. Generations at work: Managing the clash of veterans, boomers, xers, and nexters in your workplace. American Management Association: New York, 2000
3. Fernandez AR, Studnek JR. Smoking and cessation patterns among nationally registered emergency medical services professionals. Poster session presented at the annual meeting of the National Association of EMS Physicians, 2008.
4. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and Trends in Obesity Amoung U.S. Adults, 1999-2008. JAMA. 2010;303:235–241.
5. Fernandez AR, Studnek JR. Body Mass Index of Emergency Medical Services Professionals. Poster session presented at the annual meeting of the National Association of EMS Physicians, 2008.
6. Cydulka RK, Emerman CL, Shade B, et al. Stress levels in EMS personnel: a national survey. Prehosp Disaster Med. 1997;12:136–140.
7. Homan TR, Schlisserman C.. www.bloomberg.com/news/print/2010-08-03/consumer-spending-personal-incomes-in-u-s-unexpectedly-stagnated-in-june.html
This article originally appeared in October 2010 JEMS as “2010 JEMS Salary & Workplace Survey: An employee’s journey optimally for best patient care.”
- 43.3% of agencies responding perceived a shortage of certified paramedics, causing some to transition from double paramedic staffing to paramedic/EMT or paramedic/EMT-I.
- After hiring a new employee, organizations reported investing nearly six weeks, or 238 hours, in job orientation with four or more weeks spent on the street, mentoring recruits with a formal field training officer.
- Some 12.4% have reduced continuing education (CE) offerings to the required minimum, and 12.4% have increased the use of online options. A handful of organizations (1.9%) have passed some or all of the cost to the employee by no longer paying them to attend.
- One in four (26.9%) reported medics aren’t receiving adequate patient contacts to maintain skill proficiency, and 17.4% said they don’t track skill exposure or success rates.
- One out of five employees experienced an injury, losing an average of 90 workdays; more than half (54.5%) of the injuries were a result of overexertion from lifting.
- Some 38.1% of organizations reported having a formal fatigue management policy or plan, establishing an average of 38.6 maximum consecutive work hours and a minimum 11-hour recovery period.
- Operating budgets were cut an average of 9% for just under half (43.7%) of the sample, resulting in overtime reductions (65.5%), reduction or elimination of travel (55.4%), delayed cost-of-living increases (43.5%) or loss of pay for performance (32.2%)