Leadership Mindset with an Emphasis in EMS, Part Two

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

Editor’s note: This is part two of a three-part series by Dustin Axtell on what successful leadership can be in EMS. Read part one here and part three here.

Common Pitfalls in Emergency Medical Services

Understanding and acknowledging the challenges faced in today’s EMS world will importantly shed light on why EMS is vital. Common complaints identified include pay/benefits, retention, training, an opportunity for growth and the lack of leadership. A study in South Africa presented why paramedics were leaving their jobs. “The key reasons that were found in the survey are remuneration and salary, support from management within their organization, personal development, and career advancement.”1 Problems in EMS are not necessarily unique, and gaining understanding and committing to a solution is, without a doubt, the most significant barrier leaders face.


Pay and benefits are an obvious discrepancy amongst prehospital providers in the United States. Other first responder jobs were added to give reference to EMS jobs. Entry-level positions like EMTs make, on average, between $32,670 to $40,540.2 Paramedics who require more education and significantly more responsibility, on average, make between $38,469 to $48,820.3 Firefighters’ average salary range is $42,127 to $52,961, which would and should be compared to an entry-level position such as an EMT on an ambulance.4 Police officers make from $52,000 to $60,700. It isn’t clear as to why EMS makes less than their counterparts because, with similar education and qualified training, one would assume equality should exist.

Arguments presented conversely state EMS providers only require certifications for employment versus degrees. If this were true, the same requirements would apply to police officers and firefighters while adjusting and paying to other like industries will improve the ability providers have to maintain EMS as a career. Our leaders continually make excuses about not providing the same pay and benefits employees deserve. Some of these excuses are valid, but if the industry can’t financially support equality in pay, then change how reimbursement and tax bases work. Police and fire have fought to get where they are; it’s time EMS is considered equal partners.


Organizations that choose not to empower their employees can also see the lack of dedication that an employee would typically commit. The scholarly research on the role of overly rigid medical protocols on empowerment and the negative effect it has on provider efficacy suggest that a crucial element of EMS leadership is serving as a mediator between medical direction and line staff to provide an environment which is both safe for patients and fosters positive behaviors among employees. By taking away their right to feel empowered will furthermore drive the wedge between employers and employees alike.

EMS has protocols to follow when performing their jobs, and these can be interpreted in a variety of ways depending on the culture of the organization. “Protocols have been developed for everything under the sun. Now the question we have to ask ourselves: Was this effective? Or, was there just the creation of a culture of EMS zombies who operate under the ‘if this, then that’ algorithmic mindset?”5 Providing employees with the necessary tools to be successful, i.e., training and then letting them spread their wings to execute to their fullest potential, inspires them to become high performing employees.

Restricting protocols is how leaders can limit empowerment from paramedics. If providers can make autonomous decisions, then they are allowed to act within the parameters given free of repercussion and persecution. Independent choices will create a decision-making process where options are not made by good clinical judgment but met with fear. Godbe and et al. state, “When this happens, providers fear negative action and will treat patients according to a protocol despite the factors of the particular case. They may suspect something does or does not need to be done, but they follow through with the incorrect decision anyway.  They do this because of this method of inappropriate and overly rigid protocol enforcement.”5

Mistakes corrected through training and understanding promote trust contrary to errors fixed with intimidation. In East Baton Rouge (LA) Parish EMS, leaders have identified the benefit of empowering employees and were able to replace protocols with a better solution. “We taught our providers the concept of treatment goals for each type of patient and that the ‘clinical guidelines’ are your tools to achieve those goals. The clinical guidelines are not necessarily an exact process that must be followed every single time.  This runs contrary to the concept of a protocol.”5

“For projects to more effectively promote human development, they need to empower: to expand the autonomy of participants.”6 Human development, especially amongst coworkers, can ultimately determine the successes or failures of a company. “In addition, there is an efficacy reason to focus on autonomy: the more autonomous that people are the better they are able to choose and pursue the life they value and to enhance and use their valuable potentials and capabilities.  Where needed, they can promote significant social change in coordination with others, improving their present and future wellbeing and that of their fellows.”6 Employees who are amenable will emanate the culture of the organization; it’s the duty of leadership to create what learning happens. 


Traditional training comes in the form of continuing medical education hours, and a minimum requirement is needed based on state or national certifications. Organizations can provide in-house training to help, but the onus of obtaining education hours relies solely on the provider. As many people involved in medicine know, many lessons are achieved through trial and error. The main educational foundation is acquired first through an emergency medical technician (EMT) program and then paramedic school.

Continuing medical education hours have always been required to maintain a core base knowledge to allow a provider to preserve their certifications and to stay up to date with the most current educational practices. The only outlet for providers is to obtain these hours from an outside source or through a refresher class. Due to the traditional methods of training in EMS, providers are taxed with learning didactic knowledge during school and then faced with rigorous on the job training. EMS training entails classroom education and clinical work (typically 500 hours of ambulance ride time).

Expectations of new providers are unrealistic with extremely high standards and a process that takes several years to master. The hope is by continuously exposing new providers to challenging situations; eventually, improvement will occur. The problem with task saturating a trainee is the increased rate of failure on each call. Not only do the trainees have a head full of information, but the criterion is also to apply all their knowledge immediately. What if learning how to play basketball included playing a game with little to no practice before competing. The results would be devastating. Nonetheless, EMS continues to enforce this practice.

Prehospital medicine is an acquired skill, and it does take time to master, but training employees by asking them to perform to their highest capabilities the first day out of school is ludicrous. Not to mention increasing the undue stress of execution with the ordinary job stressors providers encounter on ‘typical’ calls. 

“Fifty percent of health care professionals are experiencing what they call is burnout.  It’s exhaustion low productivity and a feeling of deep cynicism.”7 Damania states, “burnout is a kind of victim shaming, it’s saying you’re not resourceful enough, you’re not resilient enough, you’re not strong enough to adapt to a system.”7 If paramedics and EMT’s take the time to self-reflect and understand that the continuous beratement through training in this manner is not just a rite of passage, but creating early onset burnout.

EMS leaders need to be the ones striving for improvement and scouring the ends of the EMS world to find better ways/ideas to practice. It’s impractical to think providers can control every last detail, and that results in fear. Having the confidence built through repetition and education will give the tools to work through any problem faced. 

First, organizations can provide all needed training in-house without forcing providers to obtain outside education. Training in-house will be a benefit to the employee, contrary to prevailing trends in the industry where internal training is rarely seen. Secondly, building culture from the pillars of EMS (physical exams, history taking, and home medication knowledge) will undoubtedly reduce the overall stress applied to employees. Rather than all three on every call, but proving proficiency in each category before they progress in training.

For example, a trainee’s only requirement on a call would be to perform a thorough physical exam. Focusing on a specific task reduces the stress put on the employee and also on the field training officer required to give pertinent feedback. As proficiency is enhanced, the employee can advance to the next phase. As with the basketball player learning how to dribble, pass, and shoot before they play a game, this, too, will build expertise achieved through repetition and specific feedback.

Whether it is a basketball player learning how to play or a paramedic learning medicine, eventually, the skills are built not only to muster one’s way through but to creating a robust everlasting foundation.  The sound footprint provides a core of competencies that each provider will be able to tap into for the duration of their careers. 


Complacency in leadership is the silent killer all parties need to combat. “The biggest risk to being great is being good.”8 EMS is still considered to be a new profession, and leaders must focus their energy on how their impact will affect employees and organizational culture. The modern era of prehospital care in the United States began in 1966. In that year, the recognition of an urgent need, the crucial element necessary for development of prehospital systems nationwide, was heralded by a report generated by the National Academy of Sciences National Research Council (NAS-NRC), a non-profit organization chartered by Congress to provide scientific advice to the nation.”9

Since 1966, the industry has gone through many changes from the advancement in training, medications, equipment, and technology. EMS has been able to develop leadership through trial and error without being many other options. Many leaders were not afforded a blueprint creating troubles current leaders have encountered today. Some of the founders of this profession still exist, and most have promoted through the ranks. The grit that comes from struggles of creating and improving an occupation from the ground up is substantial.

Early leaders used this grit to carve a path for an industry that didn’t exist before them. Much adoration must go to them for accomplishing so much with so little. Many of them are still fighting for EMS at local, state, and national levels, and without them, it is unknown where the industry would be.

Due to the development of leadership without direction or recourse, a few critical factors have occurred within the industry. First, with the lack of education requirements, many providers were promoted through seniority and attrition. Seniority being a valuable asset to a company with proof of our most tenured employees, even so, experience alone is not a viable attribute in predicting successful future leaders.

With the availability of increasing education opportunities in fields directly related to first responders, it’s essential to consider both experience and education for leadership roles.  Educational courses exist for leadership, but more importantly, understanding that more is needed to help build future leaders. 

Secondly, managers across the industry employ the term leadership as an understood term, but defining what that means to each individual and then to an organization is not only tricky; moreover, varies wildly. Becknell created a list of questions to help understand what a leader is and what a leader can be.

“Does calling someone a leader make them a leader?  Can someone manage an EMS agency without providing leadership? Does the title of director, administrator, manager, supervisor, executive or chief guarantee leadership? Are most EMS agencies truly led or simply managed? Is your state EMS director providing leadership of EMS in your state? Are the people tasked with leading EMS in the federal government exercising leadership? Is the head of your association actually leading the members somewhere? Is that charismatic speaker at the national conference a model of leadership?”10

Answering difficult questions as an aspiring leader or of people running administrations should not be shied away from but conversely should be embraced. Finding answers to challenging problems will importantly provide trust and confidence within the organization and the constituents it serves.

Toxic leadership continues to plague our industry from leaders of organizations who do more managing and less leading. Employees who function with success do so within the parameters set by management, but typically focus on self-serving interests and step over and on other employees to accomplish their goals. As these employees continue to promote, they are validated at each rank, and their roles are cemented in upper management. As Becknell stated, people in leadership roles are not necessarily leaders; they can be managers with a title.

These individuals are not difficult to find; most people reading this will have someone in mind.  How to work with, for, or above toxic leaders is unbelievably challenging and, if left alone, can cause slow degradation of motivated employees to a disgruntled and morally injured workforce. 

Leadership Styles

“The concept of leadership is as old as the history of people who tried to make groups and manage individuals for accomplishment of certain tasks.”11 “Though numerous definitions of leadership exist, yet most of the definitions share the similarity that leadership is an effort to influence, the power to make subordinates submissive and/or to transform the organization.”11 Leadership in EMS is no different; clearly, organizations are trying to find what works best for the goals and vision best suited to accomplish their mission. The trait theory, transformational, and transactional leadership are three of the more popular styles developed over the years.

Trait Theory

“The trait theory of leadership, known as ‘Great Man theory,’ was one of the first systematic efforts to study the concept of leadership in the early 20th century.”11 Blessed leaders have inherited traits that others don’t have. Stodgill states: “intelligence, alertness, insight, responsibility, initiative, persistence, self-confidence, and sociability as the unique traits of effective leadership.”11

To think some human qualities, allow certain people a leg up when it comes to leadership is no different than looking at professional athletes who have significant physical attributes. Any child can dream of playing a professional sport, but the reality is a small percentage will obtain their goals. An athlete who is born with the ability to run faster, jump higher and throw farther will have the same advantage in competition. Leaders and athletes also have the responsibility to spend as much time honing their abilities to polish their skills to be most effective and gain their particular advantage. There are plenty of athletes who could realize great athletic achievements but never lived up to their full potential. Leadership, in its own right, is no different.

Management should search out employees who exemplify some of those natural characteristics and help nurture their abilities to foster the growth of future leaders. The correlation between athletics and leadership is just as profound as how most people congruently think in the business realm. The best coaches are also the best leaders. Without a doubt, managing personalities and maximizing talent to create the best performing teams are essential. How many times are talented people either playing for a team or working in an organization but fail to have a winning formula? The coach/CEO/chief that run successful organizations can tap into a higher level of thinking/talent which is leadership.

“Any great athlete, company or leader that is actually capable of staying ahead of the pack for any significant period of time is able to do so not because they think they are the best, but because they show up every day to do better than their most important competitor of all: themselves.”12 Some inherent attributes create better leaders, thus identifying who possesses these are essential to creating the leaders of tomorrow.

Transformational and Transactional Leadership

“Burns (1978) was the first person who distinguished leadership styles based on followers’ motivation as either transformational or transactional. He defined transformational leadership as a process of motivating followers by focusing on their values to impact on their performance and envisioning a clear future for them. On the other hand, transactional leadership is a process of social exchange to have an impact on the performance of employees towards established goals.”11 Transformational leadership describes how leaders can motivate employees to improve habits and performance to better the organization.  Transactional leadership will drive the employee’s performance through self-interest via salary or bonuses.11 Both styles can benefit the organization and the employee alike.

Transformational leadership expresses that an agency is the most critical facet in motivation. Notions of being a part of something greater than oneself and the selflessness that accompanies this can cause people to put others’ best interest in front of their own. As a leader in EMS, one can ascertain that providing a high level of care to patients is of the utmost importance not only as a self-serving benefit but as an organization. Being associated with an institute that takes pride in the way it conducts business and the way it is viewed amongst its counterparts can give employees pride in who they work, furthermore creating a vested interest.

“According to Burns (1978), the transactional leaders focus on the followers’ self-interest through exchanging different things to motivate them. These exchanges may be of different natures like salary or bonus in exchange for some task accomplishment.”11 Motivation through short term benefits can provide immediate benefit to organizational performance. EMS agencies can base performance off a sliding scale to yearly salary increases, thus identifying factors like protocol deviations and attitudes as parameters for employees to strive to results in increased employee and company performance. 

Both transformational and transactional leadership are styles that can provide value to a company trying to motivate employees. Although discussed earlier with the dual-factor theory, motivating with hygiene factors will only decrease employee dissatisfaction. Ideas like empowerment, affirmation and opportunities for growth encompass the most significant attributes of motivation. If an organization is trying to accomplish long term goals, transformational leadership is more applicable. If a short-term goal is needed, then transactional leadership may be prudent. 

As an EMS leader, it’s imperative to define what goals are wanted, and enacting the appropriate style for the situation will be vital. Because EMS is fascinated with its inbred nature, leaders typically fail to look outside of EMS to improve on areas that time and time are proven to fail. Utilizing different leadership theories for desired goals is essential, but also clearly defining leadership roles within the organization can help employees align both their self-interests and company goals. If an employee knows what the expectations are, it allows both the employee and leaders the ability to set goals and hold each other accountable. Combining leadership styles will have an impact on the present and the future of the company.

“Leadership is a choice. It is not a rank. I know many people at the senior-most levels of organizations who are not leaders. They are authorities, and we do what they say because they have authority over us, but we would not follow them. And I know many people who are at the bottoms of organizations who have no authority and they are absolutely leaders, and this is because they have chosen to look after the person to the left of them, and they have chosen to look after the person to the right of them.  This is what a leader is.”13


  1. Binks, F. (2011). Retention Strategy of Paramedics in South Africa (Masters). University of South Africa.
  2. EMT Salary | Salary.com. (2019). Retrieved 26 October 2019, from https://www.salary.com/research/salary/alternate/emt-salary.
  3. Paramedic Salary | Salary.com. (2019). Retrieved 26 October 2019, from https://www.salary.com/research/salary/benchmark/paramedic-salary.
  4. Firefighter Salary | Salary.com. (2019). Retrieved 26 October 2019, from https://www.salary.com/research/salary/recruiting/firefighter-salary.
  5. Godbee, D., Brazzel, J., & Arnone, J. (2019). The Dilemma of the Protocol: Why We Need to Change This Culture – JEMS. Retrieved 27 October 2019, from https://www.jems.com/2019/10/22/protocol-dilemma-why-we-need-to-change-this-culture/.
  6. Castillo, M., & Gasper. (2011). Human autonomy effectiveness and development projects. St. Louis: Federal Reserve Bank of St Louis. Retrieved from http://login.ezproxy1.lib.asu.edu/login?url=https://search-proquest-com.ezproxy1.lib.asu.edu/docview/1698355649?accountid=4485.
  7. Damania, Z. (2019). It’s Not Burnout, It’s Moral Injury [Video]. Retrieved from https://www.youtube.com/watch?v=L_1PNZdHq6Q.
  8. Roberts, M. (2019). M&M Leadership [In person]. Doug’s Diner Located in Loveland, Colorado.
  9. Bass, R.R. (2015). History of EMS (Links to an external site.) Links to an external site. In D. Cone, H. Jane, & T.R. Delbridge (Eds.), Emergency Medical Services: Clinical Practice and Systems Oversight (pp. 1-16). Hoboken, NJ: Wiley & Sons.
  10. Becknell, J. (2014). How to Define Leadership In EMS. Retrieved 26 October 2019, from https://www.ems1.com/paramedic-chief/articles/how-to-define-leadership-in-ems-c0R5BT4ilouhyIda/.
  11. Asrar-ul-Haq, M., & Anwar, S. (2018). The many faces of leadership: Proposing research agenda through a review of literature. Future Business Journal, 4(2), 179-188. doi: 10.1016/j.fbj.2018.06.002
  12. Sinek, S. Why Better Is Better Than Best | Simon Sinek. Retrieved 3 November 2019, from https://simonsinek.com/discover/why-better-is-better-than-best/.
  13. Sinek, S. (2014). Why Good Leaders Make You Feel Safe [Video]. Retrieved from https://www.ted.com/talks/simon_sinek_why_good_leaders_make_you_feel_safe/transcript#t-152763.

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