Emergency medical services (EMS) is a relatively new profession with its foundations in the late 1960s.1 Today, almost every area of the United States enjoys EMS services, and the general public expects access to EMS. The U.S. Department of Labor’s Bureau of Labor Statistics (2019) reports that EMS work demands cognitive, physical, and emotional labor in a high-stress and unpredictable work environment. The EMS workforce is distributed among fire departments (48%), private ambulance companies (21%), governmental non-fire agencies (12%), hospitals (11%), air medical (3%), and other (5%) with the vast majority of EMS workers (72%) listing 911 response as their primary job function.2
There is also a significant part of the workforce that is volunteer or pseudo-volunteer. The majority of EMS workers are paid and are employed by municipal fire departments. The median annual salary for this group is $36,450.3 However, there exists a wide variance in the profession with regard to pay depending on geographical location, organization of the employing local government, and tenure. This complex landscape of subcategories within EMS confounds the study of the workforce.
Traditionally, the public sector of the EMS workforce has been the highest paid and has enjoyed low turnover rates.4 However, the rate of retention for EMS workers in the public sector has declined dramatically in recent years.5 Simultaneously, the demand for EMS services in the U.S. is predicted to continue to increase substantially.3 A thorough understanding of the factors affecting the recruitment and retention of EMS workers is necessary to formulate effective strategies moving forward.
Recruitment
Many U.S. fire departments are finding it increasingly difficult to fill their paramedic positions.6 This phenomenon has created a need for EMS directors to delve into the unfamiliar area of recruiting. Many traditional economists would advise that increases in compensation are necessary to solve the problem. However, public service EMS employers are rarely in a position to change compensation packages to meet the needs of the job market. Additionally, compensation is generally limited to the ability of the organization to raise funds. Transport fees for EMS do generate revenue for both public and private providers. However, rates for these fees are tightly controlled by the Centers for Medicare and Medicaid Services (CMS) and the private healthcare industry. Change in that area is likely to come much too late to solve the current crises in EMS recruitment.4 Recruitment solutions may be linked to factors other than compensation.
The main motivator for workers seeking employment in public sector EMS has long been assumed to be exclusively public service motivation.7 Public service motivation is an intrinsic motivator that exists in some portion of the population which steers people toward public service jobs to suffice a desire to serve their community. Public service motivation has been well-studied and quantified. Public service motivation is required to fill EMS positions with relatively high job demands and low pay in the traditional rational economic view. Availability of education for EMS workers in an area is an important factor that particularly effects rural communities.
The educational standards for EMS certification and licensure have increased since the adoption of the National EMS Educational Standards in 2007 by the Department of Transportation. These higher standards were adopted in response to public demand for a more-qualified EMS workforce. However, the higher standards further diminished the availability of a segment of the population for EMS work. Many rural areas heavily depend on volunteers or pseudo-volunteers to provide EMS. These same areas are likely to have substandard foundational educational opportunities and limited availability of affordable EMS education. These factors have significantly hurt EMS recruitment in rural America.7
Public service motivation is an important factor in public service recruitment, but the importance of public service motivation is limited.8 Other factors such as job fit and organizational fit also play an important role in recruitment. Recruitment messaging was once thought to be a very important factor in public service recruitment. However, Asseburg et al. (2018) argue that recruitment messaging is likely to have little impact on potential candidates who do not possess the proper public service motivation. Also, the work environment and organization fit for the potential candidate seems to be more important than ever. This suggests that clever recruitment messaging is important, but that well executed recruitment messaging is only a small part of the recruitment solution.8
One part of the solution is to realize that an EMS organization’s best recruiters are the current EMS workers. Family and friends with like values are receptive to recruitment into the profession. This is particularly true when the lifestyle of current employees is considered to be favorable by potential candidates. The reputation and community engagement of the agency are also important to this process. In the current digital age of instant communication and expectations of instantaneous response, the selection and onboarding process must be streamlined. Candidates are very likely to look elsewhere if there is an extended hiring and onboarding process. Continuous communication with candidates is essential in preventing the loss of candidates during this phase. These strategies are important, but they are cannibalistic to other EMS agencies. The more important issue is to attract candidates to the profession at a much higher rate to increase the pool of candidates. Much of what improves retention also directly improves recruitment.
Retention
Public sector EMS organizations are also experiencing increased turnover rates which compounds the recruitment problem.9 This increasing turnover rate negatively affects the quality of services provided by public EMS organizations, and the increased turnover rate comes with a monetary cost. In the Patterson et al. (2010) study, the median cost of EMS turnover was $71,613. The study also determined that there was a wide range of turnover rate and associated cost in EMS organizations depending on the type of organization and the locality of the organization’s operation. Whatever the associated cost, there does exist a price for employee turnover, and that price reduces the overall pool of funding available to offer as compensation. The findings of the study must be tempered because of the extremely small sample size and limited volume of data collected.9 This study does reinforce the complexity of the EMS workforce and illustrates many of the obstacles in studying human resource management in EMS.
The reasons for the increasing rate of turnover in EMS are also complex. Blau and Chapman (2016) conducted a small-scale study to determine why EMS workers leave the profession. This qualitative study found that EMS workers are generally satisfied with their job. Interestingly, EMTs reported a significantly higher job satisfaction than paramedics. The self-reported likelihood to leave the EMS profession was also lower among EMTs than it was for paramedics. The principal reasons for leaving EMS among paramedics included pursuing higher education and deciding to move to a new location.5 These findings might suggest that the lower-trained EMTs who generally have less job responsibilities are more content than their paramedic counterparts in a significant way. Many public EMS organizations provide incentive pay to paramedics and several organizations have experimented with performance pay for paramedics to improve retention and job performance.5 However, others would argue that EMS is not suited for performance incentives.
Woolhandler and Ariely (2012) point out that incentive pay for healthcare workers can actually decrease job motivation and performance.10 Many studies have illustrated that incentive pay can increase work performance for jobs that mainly require physical labor.11 However, the dynamic changes when intellectual and emotional labor are added to the mix. Incentivized pay programs tend to measure performance per unit of time which increases the pressure on the worker to make faster decisions in scenarios which require critical thinking. The perception of time pressure already exists in many tasks for EMS, but most EMS work scenarios have some discretionary time for critical decision making. Adding more time pressure through incentive pay programs leads to increased mistakes for healthcare workers.10
EMS providers are also required to perform emotional labor which requires the worker to behave in a way contrary to their emotions to fulfill the requirements of the job. Emotional labor is shown to cause exhaustion and other manifestations of negative stress. Decreases in job performance are also likely to exacerbate the effects of emotional labor.10
Most public sector EMS workers are affiliated with fire departments which often have an internal culture of incivility towards each other.12 This incivility is accepted as organizational culture for most emergency workers, and interpersonal incivility can even be seen as a method of group identification and group cohesiveness in some emergency response organizations. Many fire departments sharply divide their workforce into fire suppression and EMS groups through organizational constructs. This organizational structuring lends to the development of subcultures within the organization that pits fire suppression personnel against EMS personnel. Also, most fire department managers and executives relate to the fire suppression group over the EMS group. This set of circumstances leads many fire department EMS workers to seek employment with other organizations or leave the profession entirely.12
Strategies
One of the most important motivators for recruitment and retention is the meaningfulness of work.11, 13 Many people strive for their work to be meaningful to themselves and others. EMS has a great advantage in this area with frequent and explicit occasions where EMS worker action has a positive impact on patient outcome. However, EMS agencies are not always proficient in explicitly stating the meaningfulness of their workers’ efforts. Regular recognition for positive outcomes, frequent mention of meaningfulness, and messaging that emphasizes the meaningfulness of EMS work are proven strategies for recruitment and retention.
Often, EMS workers feel under equipped to accomplish the job requirements. The acquisition of quality equipment and vehicles is expensive. Purchasing equipment is cheap compared to the cost of turnover. Continuous training is also important. The only thing more stressful that running a critical EMS call is running a critical EMS call and not knowing what you are doing. So, effective and frequent training becomes a tool for retention.
When EMS workers leave the profession because of alienation from managers who prefer to identify with fire suppression or because of incivility from their peers, then the agency has experienced a preventable loss. Leaders cannot allow incivility in the workplace in the current cultural environment.
When EMS workers are treated well, recognized for the meaningfulness of their work, and are given proper training and resources, then that worker becomes the best recruiter the organization can have. Job satisfaction and job dissatisfaction are contagious. Higher turnover rates cause the need for increased recruitment. Poor recruitment can lead to unfilled positions which can increase retention problems. These problems are intrinsically connected and irreducibly complex.
Conclusion
One way to help understand the interplay of recruitment, retention, and organizational performance is to view the problem from a job resources versus job demands perspective.14 The job resources-demands theory holds that a public service worker has resources which are used by job demands. These factors interact with each other in a variety of feedback loops. For example, a worker with high public service motivation performs his or her job well with good job engagement and receives both intrinsic and extrinsic rewards.
This cycle strengthens the worker’s public service motivation. However, if the worker is overwhelmed by job demands, then the job performance is decreased, and this causes a reduction in the worker’s positive feedback and an eventual drop in public service motivation. In this light, the goal is to achieve and maintain high public service motivation and high job performance as an overriding strategy to improve recruitment and retention.
The job resources-demands theory lends itself to public EMS human resources management. Job resources such as continued medical education and public recognition for high job performance are within the purview of EMS directors and managers. Also, careful attention to work hours, equipment status and administrative job demands should be carefully monitored and evaluated to minimize amendable job demands. These steps are clearly part of the solution for the current recruitment and retention issues within public EMS organizations. However, there are likely other solutions which haven not come to light. The complexity of the EMS workforce and the nature of the profession has made reliable empirical data on the issues scarce. More concentrated research in this area is required before all possible solutions are revealed.
References
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2. Rivard, M. K., Cash, R. E., Mercer, C. B., Chrzan, K., & Panchal, A. R. (2020). Demography of the national emergency medical services workforce: A description of those providing patient care in the prehospital setting. Prehospital Emergency Care, 1–8. https://doi.org/10.1080/10903127.2020.1737282
3. Bureau of Labor Statistics, US Department of Labor. (2019). Occupational outlook handbook, EMTs and paramedics. https://www.bls.gov/ooh/healthcare/emts-and-paramedics.htm#tab-9
4. Office of EMS, National Highway Traffic Safety Administration. (2008). EMS workforce for the 21st century: A national assessment (DOT HS 810 943). Government Printing Office.
5. Blau, G., & Chapman, S. A. (2016). Why do emergency medical services (EMS) professionals leave EMS? Prehospital and Disaster Medicine, 31(S1), S105–S111. https://doi.org/10.1017/S1049023X16001114
6. National Highway Traffic Safety Administration. (2011). 2011 national EMS assessment (DTNH22-09-C-0128). Government Printing Office.
7. Freeman, V. A., Slifkin, R. T., & Patterson, P. D. (2009, June 1). Recruitment and retention in rural and urban EMS: Results from a national survey of local EMS directors. Journal of Public Health Management & Practice, 15(3), 246–252. https://doi.org/10.1097/PHH.0b013e3181a117fc
8. Asseburg, J., Homberg, F., & Vogel, R. (2018). Recruitment messaging, environmental fit and public service motivation. International Journal of Public Sector Management, 31(6), 689–709. https://doi.org/10.1108/ijpsm-08-2017-0217
9. Patterson, P. D., Jones, C. B., Hubble, M. W., Carr, M., Weaver, M. D., Engberg, J., & Castle, N. (2010, March 3). The longitudinal study of turnover and the cost of turnover in emergency medical services. Prehospital Emergency Care, 14(2), 209–221. https://doi.org/10.3109/10903120903564514
10. Woolhandler, S., Ariely, D., & Himmelstein, D. U. (2012). Why pay for performance may be incompatible with quality improvement: Motivation may decrease and gaming of the system is rife. BMJ: British Medical Journal, 345(7870), 5. https://doi.org/10.1136/bmj.e5015
11. Pink, D. H. (2009). Drive: The surprising truth about what motivates us. Riverhead Books.
12. Cash, R. E., White-Mills, K., Crowe, R. P., Rivard, M. K., & Panchal, A. R. (2019). Workplace incivility among nationally certified EMS professionals and associations with workforce-reducing factors and organizational culture. Prehospital Emergency Care, 23(3), 345–355. https://doi.org/10.1080/10903127.2018.1502383
13. Ariely, D. (2010). Predictably irrational: The hidden forces that shape our decisions. New York: Harper Perennial.
14. Bakker, A. B. (2015). A job demands-resources approach to public service motivation. Public Administration Review, 75(5), 723–732. https://doi.org/10.1111/%28ISSN%291540-6210/issues
