The Trip Report: Leaving EMS…for a While

Reviewed This Month

Exiting the Emergency Medical Services Profession and Characteristics Associated with Intent to Return to Practice.  

Authors: Cash RE, Crowe RP, Agarwal R, Rodriguez SA, Panchal AR. 

Published in: Prehosp Emerg Care, 2018 Jan–Feb; 22(1): 28–33.  

This month we discuss a topic many of us have probably secretly (or not-so-secretly!) thought about, especially after a rough shift: leaving our profession. We probably all have some thoughts as to why our colleagues do this. However, there is very little evidence to support or refute our guesses. 

This article—“Exiting the Emergency Medical Services Profession and Characteristics Associated with Intent to Return to Practice,” published in Prehospital Emergency Care—adds some evidence to this discussion. The authors evaluate reasons people exit EMS and identify common characteristics among those who have left but intend to return. This publication is important for leaders trying to retain their workforces. 

The study had three objectives: The first was to describe, on a national level, the proportion of EMS professionals who left EMS but intend to return. The second was to compare demographic and employment characteristics of individuals who reported being likely to return to EMS versus those who reported being unlikely to return. Finally the authors assessed the prevalence of key factors contributing to the decision to leave EMS. Lead author Rebecca Cash and her team used a census of nationally certified EMS professionals to meet these objectives. 

A census is different than other surveys. Most surveys cannot reach everyone in a population. There are many reasons, including not having a method or the resources to contact everyone. Therefore, most surveys are targeted to a sample of the population. A lot of work generally goes into selecting a sample that accurately represents the overall population. A census is great if everyone in the population can be reached. A census is taken in our country every 10 years. This is possible because our government has a method to reach almost all of us. 

Cash and her coauthors were able to take a census because they targeted nationally certified EMS professionals. The NREMT has a database and regularly sends surveys to all nationally certified EMTs and paramedics. At the time this study was performed, there were more than 300,000 of them, and everyone with a valid e-mail address (95% of those with an NREMT certification) received an invitation to participate. They were asked demographic questions that included how much experience they had, certification level, service type they worked for, and type of service provided (9-1-1, medical transport, etc.). They were also asked how many organizations they currently worked for as an EMS professional. Those who replied zero were then asked additional questions specifically about exiting EMS. 

What is really novel about this manuscript is that most of the literature on leaving EMS is focused on those who intend to leave but haven’t yet. These authors obtained information from those who’ve already left the field.  

Results

Only about 10% of nationally certified EMS professionals replied to the census. This response rate is less than ideal, but because there are so many nationally certified EMTs and paramedics, there were still 32,114 individuals who completed the census. Of those, 1,248 (3.9%) had left the field. These 1,248 individuals comprised the study population. 

For those who left, a lot of factors influenced their decision. Four reasons were reported by more than 50% of respondents: The desire for pay and benefits was reported most often (64.7%); this was followed by the decision to pursue further education (60.4%), dissatisfaction with organizational management (54.7%), and desire for a career change (54.1%). 

Among the study population, 72.3% indicated they were likely to return to the field. The authors found a statistically significant difference in the likelihood of returning to EMS based on race, with more minorities indicating they were likely to return compared to nonminorities (80.5% vs. 69.0%, p<0.01). There was no statistically significant difference in the likelihood of returning to EMS by gender (male 70.3% vs. female 71.9%, p=0.58). Interestingly, as experience increased the likelihood of returning decreased, and this result was statistically significant (p<0.001). Additionally, the longer an individual had been away from the field, the less likely they were to return (p<0.001). The type of agency the individual worked for (p=0.696) and type of service provided did not have a statistically significant relationship with intent to return to EMS. 

When putting their results into context, the authors noted that the percentage of females who left the field was higher than the overall percentage of nationally certified women in EMS. Females represented about 40% of those who left, compared to 27% of those in the NREMT database. This result was similar for minorities, with 19% who left the field compared to about 11% of the nationally certified EMS population. 

The authors correctly postulated that a possible explanation for the inverse relationship between EMS experience and the likelihood of returning to the field may be due to individuals retiring. Overall, only 17% of all respondents indicated they retired; however, among those with at least 16 years of experience, retirement was the most important factor influencing their likelihood of returning to the field. 

The result indicating that 72% of those who left intended to return to EMS also needs to be evaluated critically. The respondents were individuals who left EMS but still had an NREMT certification and valid e-mail address and took the time to complete the survey. This is a population that clearly still has a little of that EMS bug. In other words, that 72% is likely an overestimate. However, as the authors point out, this is the population leadership should target when looking to increase their EMS workforce.  

Pay and Benefits

I couldn’t get away without discussing the 64% of respondents who indicated they left the field due to a desire for better pay and benefits. This probably confirms what many of us would have guessed.
However, when dissecting this result, we need to fully understand what it tells us and what it doesn’t. This was a “pick all that apply” question: The respondents were not asked to rank the most important factor, but rather to list all the factors. So we know pay and benefits are definitely a factor for almost two-thirds of those who left. However, the authors were unable to tell us if this was the most important factor. 

It’s important to make this distinction because, as the authors note, a previous study found the desire for better pay and benefits was the least important factor. In other words, when putting these results into context, the desire for better pay and benefits appears to be important for most of those who leave the field, but other factors may weigh more heavily into their decisions. 

All studies have some limitations. One of the most important to this study is that it only evaluates nationally certified EMS professionals. It’s possible that those who never held a national certification or those who let it expire might have different reasons for leaving the field as well as different factors influencing their likelihood of returning.

As mentioned above, the response rate was low, and even though the total number of individuals who participated was over 30,000, it’s possible the 10% who responded do not accurately represent the entire population. In other words, these results may not be generalizable.

The factors assessed are limited to those included in the survey questions. It is possible that factors not included in the survey are important to an individual’s reason for leaving the field or likelihood of returning.
Finally, it is unclear from the results presented in this manuscript whether there is a difference in the outcomes of interest based on the region of the country in which respondents live and work.

This is a great study, and I congratulate the authors for publishing these important results. I also would like to encourage everyone to reply to surveys from leading organizations and associations in our field. As this manuscript demonstrates, your answers will be used to inform decision-makers in our profession.  

Antonio R. Fernandez, PhD, NRP, FAHA, is research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill. He has been a nationally certified paramedic since 2005 and completed the EMS Research Fellowship at the National Registry of Emergency Medical Technicians.