Employee Retention: Applying Hospital Strategies to EMS

EMS services have traditionally struggled against funding cuts and bureaucrats to provide for the needs of their communities. Now, many services find themselves in an internal battle. Ambulances are being parked as paramedics and EMTs leave the profession at record rates. In some parts of the country, there is 20% turnover.¹ The problem, though, doesn't exist simply within EMS. One hospital study found that one-fifth of the responding nurses intended to leave their current positions.² Hospitals concerned about replacement costs and quality of care use a number of strategies to retain their workforce that EMS organizations could also implement to retain existing staff.

     Like EMS, the current nursing shortage includes both supply and demand. Nursing schools cannot turn out enough graduates to keep up with the increasing demand. EMS employment needs are projected to grow by 21%-35% over the next few years.³ Many EMS and nursing staff are also reaching retirement age. With increasing shortages from both ends, EMS services will be competing with each other and will need to make provisions for maintaining their current staff.

Retention Efforts
     Retention efforts should begin from Day #1 with new hires, who often feel alone in their new work environment. Hospitals found that healthcare workers begin to think about leaving 180 days into their job, and half of them leave after the first year.⁴

     Assign each new employee a mentor to help them through the early processes of learning a job. This mentor should keep a watchful eye on the new EMT to ensure he is not overwhelmed with the new procedures and has time to gain experience. Managers should listen carefully to their mentors and not schedule new workers on independent assignments until they have demonstrated documented competence handling the variables of a call.

     Hospital studies recommend meeting with new employees every two to three months to make sure they're receiving adequate support and guidance.⁴ These meetings also open lines of communication with the manager to discuss any areas of concern that arise. Hopefully, this would head off any problems before the new employee starts looking elsewhere.

     Besides retention meetings, managers could hold social events to encourage friendship between the new employees and existing staff. Friendship helps retention by increasing the new employee's bond to the department and by creating an environment where the new employee feels comfortable and accepted. Good-natured ribbing of "newbies" is an old tradition that encourages bonding, acceptance and adaptation to the department. Mentors, meetings and friendships all work together to make new employees feel part of their new environment and reduce their intent to leave by reinforcing their importance and position in the workplace.

Generation X
     Managers must do more than establish a workplace conducive to new employees. Through their management style, they directly impact the job satisfaction and retention of existing staff. Generation X employees refuse to accept a dictator-type manager. They want management on a personal, interactive level with them. Managers must talk and laugh with their staff and be able to stand up for them. The manager-employee relationship creates a supportive environment that allows employees to be comfortable and grow. This, in turn, leads to self-actualized employees who are motivated to work hard and are less likely to leave because they have a bond with management.

Promote Education
     Another retention method to increase self-actualization is through education. Most hospitals now reimburse tuition for nurses; some use other methods to support education in an effort to increase nurse job satisfaction.

     One hospital provides "five days a year for education away from the facility, and nurses are paid both time off and tuition."⁵ Another hospital provides a day off every four weeks for education.⁵ These programs allow nurses the opportunity to grow personally and to bring new ideas and concepts back to the department that can be used to improve their workplace. Taking this proactive stance toward education in EMS would yield the same results, giving EMTs and paramedics more say in departmental decisions because of their "expert" knowledge and increased satisfaction with their current workplace.

Money Motivates
     The importance of pay to retention in paid services has been debated. Some argue that salary isn't an issue; however, a study found that nurses ranked pay second in importance as reasons to stay with an employer.⁶ Because of this, pay is an important retention strategy for hospitals.

     With downsizing and reengineering in today's workplaces, Generation X employees feel less loyalty to an employer than employees of previous generations. An employer who fails to offer competitive wages will find it increasingly difficult to attract new employees, who are more often than not applying with the highest payer. Sherwood Hospital went from a 3% turnover rate to 18% in just two months when competing hospitals increased nursing salaries. When Sherwood Hospital finally increased its wages, the turnover rate for nurses decreased to 1% in four months.⁵ Obviously, keeping EMS pay competitive is an effective retention strategy. Healthcare workers have shown they will follow the dollars. Conversely, if they are paid well by their current employer, it's one less reason to look elsewhere for employment.

Flexible Scheduling
     Hospitals have found that healthcare workers shop for a schedule that fits their needs. A department that offers a variety of schedules increases its appeal to a wide spectrum of staff.

     Both flexible and self-scheduling are significant ways to increase worker satisfaction. These methods go beyond simply letting an employee pick the schedule that is best for him from existing options; they allow employees to self-determine their schedule by providing the latitude to individually tailor their work hours. Generation X employees want jobs that accommodate their family needs and personal activities.

     The American Hospital Association urges its members to "minimize, if not eliminate, shift rotation and allow creative and flexible staffing arrangements that are tailored to meet staff needs."5 These innovative scheduling methods allow employees to adjust their work schedules to the rest of their lives, resulting in improved job satisfaction and job retention.

Staff Up
     Hospitals have found that inadequate staffing levels lead to nurse job dissatisfaction, increased turnover, exhaustion and a stressful environment that increases the possibility of nursing errors and poor patient outcomes. One study found "the ratio of total nurse staffing to patients was significantly related to in-hospital mortality."⁷ With concerns like these, the California state legislature has regulated appropriate nursing ratios for hospitals to maintain. EMS has focused on the UhU (Unit hour Utilization) measure for determining proper workloads for EMS crews; however, these UhU-driven systems must be balanced against the potentially detrimental environment they create for both the employee and patient. EMS consultants Fitch and Associates notes that, "High UhUs, coupled with long shifts and little opportunity for rest, are a potential risk factor and employee satisfaction issue."8 Employers must establish staffing levels that provide for the health of both their workers and patients. In turn, establishing these levels would help ensure EMS staff retention by increasing job satisfaction and the ability to do their job properly. Limiting mandatory overtime by hiring additional staff or utilizing other resources would also limit the exhaustion of performing their duties.

Share Responsibilities
     Magnet hospitals, which have been created to help retain nurses, have demonstrated less than half the turnover rate of other hospitals.⁹ Implementing systems used by magnet hospitals into EMS, such as shared governance models or nursing councils, will positively influence turnover rates by increasing the control EMTs and paramedics have over their work environment. These systems allow employees to participate more in the decisions that affect them through additional responsibilities that provide creative challenges, such as clinical career ladders or work groups created to solve departmental problems. This fosters employee development and reinforces the bond between the department and employees by demonstrating the value of the organization for them and their abilities. Any measure that increases staff input and control in their workplace, from CEO-interactive venues to daily manager rounds seeking employee feedback and increased use of nursing-style councils, will increase retention by making the EMT or paramedic a valued team player.

Create A Community
     Just as shared governance enhances employees' sense of connection to the organization, so does a feeling of community in the workplace, which creates a sense of commitment and belonging.¹⁰ Examples abound of busy shifts or taxing calls where EMS staff pulled together as a team and felt connected to each other and their department. Closely linked to community in the workplace is the concept of job embeddedness, which reasons that the more employees realize what they would be giving up if they leave an organization, the more likely they are to stay. Embeddedness comes from links to the job through work and non-work activities, and through losses, such as leaving well-liked fellow employees. Efforts to enhance both community and embeddedness include supporting activities that create personal connections, such as after-hour get-togethers and departments caring for employees during life crises.

Keep In Touch With Technology
     Technology has also been used to increase job satisfaction. Hospitals have acquired systems that permit nurses more time at the bedside to concentrate on nursing skills. EMS agencies should also consider acquiring new technologies that increase the efficiency with which EMTs and paramedics perform their skills and cut down on the stress and chaos of managing difficult calls.

Summary
     Retention strategies are a priority for EMS organizations. These strategies must be broad and varied to address the variety of reasons employees leave healthcare organizations. The value of creating these programs should manifest itself through increased employee satisfaction and an increased sense of belonging to the organization.

References

1. 1. Williams DM. 2005 JEMS salary & workplace survey. JEMS 30(10): 36-55, 2005.
2. Rambur B, Palumbo VM, McIntosh B, Mangeon J. A statewide analysis of RNs' intention to leave their position. Nursing Outlook 51(4):182-187, July/Aug 2003.
3. Lowe B, Bolton B. 21st century EMS retention strategies. Emerg Med Serv 31(11): 75-77, 2002.
4. Martin C. Staying power. Nursing Management, 35(3): 20-27, 2004.
5. Solving the Nursing Shortage: Best Practices for Recruitment and Retention of Nurses. www.afscme.org/una/sns08.htm.
6. Lacey L, Shaver K. Findings from the 2001 Survey of Staff Nurses in North Carolina. www.nursenc.org/research/retain-staff.pdf.
7. Sasichay-Akkadechanunt T, Scalzi C, Jawad A. The relationship between nurse staffing and patient outcomes. J Nurs Admin 33(9): 478-485, Sep/Oct 2003..
8. Fitch and Associates. Does uHu accurately measure workload? Management Focus 20 (3): 1-2, Fall 2005.
9. Upenieks V. What's the attraction to magnet hospitals? Nursing Management 34(2): 43-44, 2003.
10. Manion J, Bartholomew K. Community in the workplace: A proven retention strategy. J Nurs Admin 34(1): 46-53, 2004.

Robert Powers, BS, RN, EMT-P, is emergency preparedness coordinator for the Emergency Services Institute, WakeMed Health & Hospitals, in Raleigh, NC.