Leadership Mindset with an Emphasis in EMS, Part One

First responders at a crash scene.
Photo/National Highway Traffic Safety Administration

Editor’s note: This is part one in a three-part series. Read part two here and part three here.


A reference guide was created to direct past, present, and future leaders to obtain knowledge, skills, and abilities about the leadership mindset. Historically, leaders are dealt with difficult decisions by determining the quality of their leadership by way of choices between self-preservation or the betterment of the employee. The guide will push past common and current management styles to aide leaders in finding a more effective form of leadership. Leadership makes up the fabric of our being from a minuscule thought to the most grandiose of decisions.

Emergency medical services (EMS) comprises EMTs and paramedics who provide services to the community that without would create a vacuum of the sick and injured with no place to go. Ambulances are the intermediary and extension of the hospital performing treatments and care in austere environments. The goal for EMS is to continue to build on the foundation of leadership currently in place. There will also be an examination and discussion on determining your “why” as a leader in reviewing current literature through EMS leadership as well as common leadership styles.

Equally important will be identifying common pitfalls in EMS and how the application of leadership is used to mitigate common misconceptions and biases. A conversation is executed on the core values that are the foundation for leadership, including trust, transparency and communication while implementing ideas from great leaders. Furthermore, recognizing our strengths and weaknesses as an industry will allow future leaders the opportunity to excel by way of continued transparency to lead with an employee-centered focus. Finally, putting into action the reviewed examples of leadership to make applicable the information presented and why leadership in EMS is a fundamental component to leveraging the future direction of the industry. 

“All organizations are similar in their messages. The what, how and why. The difference between the great leaders and everyone else is how they communicate those three ideas. The great leaders start with the inverse and communicate the why first. People don’t buy what you do; they buy why you do it. If you talk about what you believe, you will attract those who believe what you believe.”1

The Why

The why is to create a piece of literature that will move people past typical and outdated ideas of leadership to help bridge the gap in knowledge for future leaders, current leaders and those aspiring to elevate their leadership knowledge, skills and abilities. Therefore, by offering the reader an opportunity to tap into core values of trust, transparency and communication, the potential to redirect ideals of what leadership is and can be will occur. With the perceived lack of overall exceptional leaders in EMS, the industry lends to a potential collapse in global growth, and the metrics are not readily available as to why.

The finite parameters have been reviewed in regards to pay, benefits, employee retention, performance, to name a few. Yet, there is very little research that has been done about leadership in EMS individually. Most of the information available regurgitates common themes of why people are underperforming as leaders. Some metrics lend to poor leadership, causing the employee retention problem. As the adage goes, people don’t quit jobs; they quit leadership.

EMS is a proud industry that is still reasonably new in regards to most industries with like duties, i.e., police and fire. A parallel that has left industry leaders struggling to find its place at the table. Leadership Mindset will shift the focus from short-range goals to the long game, which in turn helps leaders achieve lasting success. Leadership is undervalued, underemphasized and exaggerated. As the industry grows, so too will visionaries proving to create a work culture worth being a part of.

The How

The industry needs to build a culture worthy of our best efforts, by finding the why the how will follow. By hiring the right people that fit the organizational core values, then exposing them to a training process that mimics these values will unquestionably set the tone of the organization. Finding field training officers (FTOs) that walk the walk and not just talk the talk will afford new employees an early exposure to the core values – promoting based on high trust, transparency and communication versus on performance alone.

Organizations need to create a management team to reinforce the core values through a commitment to supporting the most valuable commodity – our people.  Laying the groundwork for generations to come has to start now. Leadership is talked about as freely as the changing weather and defining it is done just as easy; nonetheless, breaking down precisely what it is and how to implement it typically causes pause. EMS is an invaluable asset in our communities, and our citizens deserve the highest level of care possible.  

The What

Leadership is what separates underachievers from overachievers. Leadership is the key to a thriving organization where great people are making the best decisions. The problem with leadership in EMS is unlike similar industries that have been around for centuries; EMS is only decades old and haven’t had the opportunity to learn from its own mistakes. The early leaders in EMS achieved these roles primarily through seniority, attrition, cronyism and limited education.

Like all industries, there are diamonds in the rough that have figured it out, however EMS has limited examples of what is successful leadership. A fatal error that continues to arise is the lack of education applied to identify and develop leaders that will help the industry not only accomplish goals immediately but help advance the industry into the next phase of success.

A crucial step will be identifying the employees that have leadership qualities and exploiting it for their benefit and the organizations alike. Without a doubt, the industry needs to provide our people with a foundation of fundamental core values that comprises what great leaders are and gives reference to how it applies specifically to current and future leaders in the industry. Using the why as the foundation to our how and what will keep leaders focused on what’s essential: trust, transparency and communication. 

Literature Review

A literature review of EMS leadership gives the reader a frame of reference to where the industry has been and currently is. The overwhelming challenge of identifying actual stats to “rate” leadership in EMS doesn’t readily exist. Several topics about specific tasks within EMS have been researched, i.e., evidence-based medicine, cardiac arrest survivability, employee retention, to name a few. A few resources were identified and will be discussed to give the reader a basis for what is considered current information or practice.

Evidence-Based Literature

Evidence-based medicine is a collective term amongst those in healthcare, and most providers understand the benefit by having evidence backing the decisions we make on a day-to-day basis. Through observation, the majority of personal experiences are due to the lack of written evidence, and the majority of prehospital providers utilize their skills and information taught in their respective EMT or paramedic schools. Keeping EMS providers in the proverbial loop with the most current evidence-based medicine is a monumental task alone, much less implementing new concepts into leadership. 

Evidence-based leadership is a new term that has been steadily rising in the business ranks but has yet to hit the prehospital world. Looking into a study on leadership with evidence-based practice gives reference to an industry that has little practice performing. “Although research reviews and primary studies do exist, empirical support within nursing regarding leadership for evidence-based practice (EBP) is limited, most particularly when the focus is institutionalization.”2 The study describes the differences between a “role-model” hospital and a “beginner” hospital and whether they embrace the leadership that supports evidence-based practices. Results showed the “role-model” hospital emanated more of the leadership themes that needed to be institutionalized. 

“Our findings identify observable EBP supportive behaviors enacted by multiple levels of leaders; build upon and extend the limited research base regarding such EBP-related behaviors by providing more breadth and demonstrating multilevel and dynamic interactions; and provide a pragmatic, albeit preliminary leader behavior framework. This framework should be relevant for both leaders “at the coalface” and health services researchers interested in developing leadership interventions designed to enhance successful implementation.”2 This study showed that when implemented, the climate of an organization will adopt the values leaders are trying to convey.

A Leadership Guide

A Leadership Guide to Quality Improvement for Emergency Medical Services (EMS) Systems is a book written to aid CEOs and chiefs of EMS organizations. “Leadership involves efforts by senior leadership and management leading by example to integrate quality improvement into the strategic planning process and throughout the entire organization and to promote quality values and QI techniques in work practices.”3

Leading by example is a necessary quality all leaders should embrace. Leaders should not ask anything of their employees that they are not themselves willing to do. When was the last time the chief of an organization was found cleaning an ambulance? Some might say they have paid their dues, others might say they should spend time doing other things, but the reality is leaders who demonstrate they can perform any task in the organization builds trust. As movement up the career ladder transpires, having a mindset that each promotion should equate to working harder rather than leaning on our employees to carry the load.

“All members of the EMS leadership system should assess how well they each “˜walk the talk’ of quality improvement. The action might be accomplished, for example, through internal customer feedback on their leadership (“˜coaching’) performance and how they might improve. Since in the early stages of QI, staff may be apprehensive about evaluating the boss, the use of anonymous feedback may be helpful. Eventually, however, anonymity may be unnecessary as fear of reprisals lessens.”3 Undoubtedly, creating a culture of trust, transparency, and communication will not only allow for feedback but it will promote it.  Whether it be from the lowest level in the organization to the highest, the perspective from the people doing the job should be embraced.

The Dual Factor Theory

Looking at the information on why EMTs and paramedics leave EMS can be summed up by viewing the industry as a stepping stone. EMS professionals choose to either go for another organization or because the pay was inadequate. “A desire for better pay and benefits was a significantly more important reason for EMT-Paramedics’ exit decisions than for EMT-Basics.”4 This study tells us two main ideas. Either the morale amongst EMS providers is not as bad as most of the industry thinks, or the limitations to the survey’s metrics don’t tell the whole story.

Fredrick Herzberg studied the effects on employee motivation and job satisfaction. The dual-factory theory describes the two primary factors as motivational and hygiene factors. Hygiene factors include employee pay, benefits, working conditions, equipment to perform the job while motivational factors include, opportunities for growth, gratitude, empowerment and responsibility.5 The ideal environment has both high hygiene and high motivational factors.5 The agencies achieving both elements would be considered an atypical organization, but they do exist.

Finding them might be evener harder to identify. The reality is people want to feel safe and trusted. The problem with creating high hygiene in a work environment is it only decreases employee dissatisfaction whereas increasing motivation comes from making people feel vested and belief in something greater than themselves. As leaders, the focus on a balance that works within the organization is necessary, however increasing motivation over hygiene will heighten the ability to retain happy, motivated employees. 

Literature Summary

There is limited information found for EMS leadership, and that may not be a bad thing. Leaders of tomorrow have an opportunity to write their own narrative and correct the atrocities they feel need to be corrected. The literature supports material about positive leadership, but very little specific to EMS. Embracing leadership practices from other industries and other leaders will ease the burden current, and future leaders have. Corralling the information that makes sense and feels right combined with experiences, is the path that trail-blazing leaders needed to take when they paved the way in their respected industries. Without having a regimented outline of what EMS leaders look like or how they should be performing gives the next generation the autonomy to create their own story.

Herzberg’s thoughts on employee motivation rein true today in EMS. Organizations predicating themselves on hygiene factors alone will face struggles of getting maximum engagement from employees. Having the tangible equipment to perform the job is necessary, but as Herzberg stated, this will only reduce dissatisfaction. Real motivation comes from creating an environment of a brotherhood/sisterhood where choices are made for each other rather than selfishly.

Project Methodology

A document was created through a literature review, identifying examples of industry leaders who exemplified superior leadership skills, while their ideas were used in conjunction with the writer’s personal experiences. Utilization of videos, scholarly journals, articles, personal interactions and lessons were the primary vehicles of information. Ideas and information discussed through several outlets, including brainstorming and then organizing the data into an outline, prematurely structured the information to be conveyed. Finally, the applied project guidance document was used to steer the report in an organized, complete manner.


  1. Sinek, S. (2009). How Great Leaders Inspire Action [Video]. Retrieved from: https://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action?language=en#t-462795.
  2. Stetler, C. B., Ritchie, J. A., Rycroft-Malone, J., & Charns, M. P. (2014). Leadership for evidence-based practice: strategic and functional behaviors for institutionalizing EBP. Worldviews on evidence-based nursing, 11(4), 219—226. doi:10.1111/wvn.12044
  3. United States. Maternal Child Health Bureau. (1997). A Leadership guide to quality improvement for Emergency Medical Services (EMS) systems. Washington, D.C.: U.S. Dept. of Health & Human Services, Public Health Service: Distributed by U.S. G.P.O.
  4. Blau, G., & Chapman, S. (2016). Why do Emergency Medical Services (EMS) Professionals Leave EMS?. Prehospital And Disaster Medicine, 31(S1), S105-S111. doi: 10.1017/s1049023x16001114
  5. Kuijk, A. Two Factor Theory of Motivation by Frederick Herzberg | ToolsHero. Retrieved 8 October 2019, from https://www.toolshero.com/psychology/theories-of-motivation/two-factor-theory-herzberg/.
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